SCREENING SCREENING SCREENING Fill out your screening questionnaire below. Open Questionnaire Screening Questionnaire Name * First Name Last Name Guardian name, if filling out for a child or dependent. Questions are all in first person, if filling out for a child or dependent please answer all questions in regard to them. First Name Last Name Email * Phone Country (###) ### #### I recognize that this is an unencrypted form submission and that I don't have to enter any personal or medical information that I don't feel comfortable submitting * Yes No Gender * Age * Have you ever been told that you have a tongue tie? Yes No Is your mouth open while resting or sleeping? Yes No What percentage of the day (including sleeping) would you say you are mouth breathing? Do you ever snore when sleeping? Yes No Do you experience difficulties in breathing or breathe with a lot of effort? Yes No Have you ever been told, or do you feel that you clench or grind your teeth? Yes No Do you have any TMJ discomfort? Yes No Do you move around frequently or wake frequently during sleep? Yes No Did you struggle with breastfeeding as an infant? Yes No Do you have allergies? Yes No If yes, please list: Have you ever gotten recurrent sinus or ear infections? Ear Sinus Both Neither Have you ever worked with a speech and language pathologist? Yes No Have you ever had braces or orthodontic treatment? Yes No Would you say you have "straight" teeth? Yes No How would you describe your face shape? Round Square Oval Rectangle Do you have any habits such as; thumb/finger sucking, extended pacifer use (for children), nail biting, hair chewing, ice chewing, etc? Yes No If yes, please list: Have you been diagnosed with or show signs or symptoms of ADD or ADHD? Yes No List any medical conditions (physical and psychological) that you feel comfortable sharing: i.e. scoliosis I sleep soundly all through the night. ~ Strongly Disagree Disagree Neutral Agree Strongly Agree I feel fully refreshed when I wake up in the morning ~ Strongly Disagree Disagree Neutral Agree Strongly Agree Please list anything else you would like me to know: How would you like to recieve your results? Email Text Message Thank you for fillling out the screening questionnaire!I will evaluate your responses and send you my evaluation.
