Please take your time to fill out this form for yourself (or your child). Be as thorough as possible. The more information I have, the better!The form does not auto save, so be sure to start and finish in one session. Name * First Name Last Name Name of person completing form (If different) Email * Birthday: * Approximate Weight Approximate Height What is your goal or intention with doing myofunctional therapy? * Have you ever been told that you have a tongue tie? * If you haven't been diagnosed, do you suspect that you have a tongue-tie? * Did you have difficulty breastfeeding as an infant? * Were you mainly breast fed or bottle fed? * Were you born prematurely? * Are you a picky eater or were you as a child? If yes, please explain. * Do you keep your mouth open while resting, watching tv, or using the computer? * What percentage of the time would you estimate that your mouth is open, 0-100? * Do you have asthma? * Do you have difficulties in breathing or breathe with a lot of effort? * Do you ever snore when sleeping? * Do you wake feeling refreshed in the morning? * Do you clench or grind your teeth? * Do you frequently wake up to use the restroom at night? * Do you move around a lot during sleep? * Do you sleep in abnormal/contorted positions? * Do you wake up sweaty? * Do you get saliva on your pillow? * Do you wake up with a dry mouth? * Do you have chronic dry/chapped lips? * How often are you sick? * Do you have allergies? If so, what are they? * Do you get easily tired or out of breath after light exercise? * Do you have speech or pronunciation problems? Have you ever worked with a speech and language pathologist? * Have you had any orthodontic treatment? If yes, please explain your orthodontic history. * How many cavities have you had in your life (best estimate)? * Did you have or do you currently have any sucking habits such as thumb/finger sucking, an extended pacifier habit, sucking on blankets or toys, etc.? * Do you have now or have you ever had any chewing habits such as biting nails, chewing on pencils, chewing on hair, etc? If yes, please elaborate: * Have you had a history of ear or sinus infections? If yes, please explain. * Do you have any digestive issues? i.e frequent bloating, gassiness, acid reflux, or any other digestive concerns. * Do you now, or have you ever had, difficulty swallowing pills? * Do you have a strong gag reflex? * Have you been diagnosed with ADHD? If not, do you feel you display signs or symptoms of ADHD? * Do you struggle with anxiety? * Do you have scoliosis? * Do you have poor posture? If yes, please explain. * Do you have any chronic pain? If yes, please describe in detail: * Do you get frequent migraines or headaches? * Do you feel a lot of tension in your head/neck/shoulders? * Do you have popping or clicking in your jaw? * Do you have jaw discomfort? * Do you feel like your jaw range of motion is limited? * Have you ever seen an ENT? If so, what for? * Please list in detail any other medical conditions that you have been diagnosed with or had treatment for * What other medical, health or wellness professionals are you currently working with, if any? * Please list in detail any other information I should know: * Thank you for submitting!You’re all caught up for now, once you get your kit you can take the photos and videos to upload and get scheduled!
