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Orofacial Myofunctional Therapy Assessment
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Name *
Date of Birth *
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Has anyone ever told you that you may be tongue-tied?
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As a baby were your breastfed or bottle fed?
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Did you have difficulties feeding as an infant?
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As a child did you have a history of ear infections?
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Have you ever had a finger or thumb sucking habit?
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As an infant, child, and/or adult, have you had any non-food allergies?
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What are you allergic to?
How do you manage your allergies?
Do you often feel your nose is blocked or congested?
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Do you have a history of other breathing problems?
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Do you notice you breathe more often through your mouth than your nose?
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Do you notice occasionally that your mouth is open at rest?
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Do you sleep with your mouth open or closed?
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Where does the tip of your tongue rest in your mouth?
Where does the back of your tongue rest in your mouth?
Do you have any difficulties swallowing pills or certain foods?
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Do you have a hyperactive gag reflex?
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Do you chew with your mouth open?
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Do you feel like you need water to wash down your food when you eat?
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Do you have trouble swallowing or a history of choking?
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Have you had your tonsils removed or have you been told your tonsils are enlarged?
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Does it ever feel difficult to breathe and eat or chew food at the same time?
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Have you ever had food allergies or sensitivities?
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If you answered yes to allergies, which foods?
As an infant, child, or adult, have you ever experienced any issues with digestion (digestion, stomach aches, bloating, burping, gas, acid reflux)?
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Have  you ever had trouble with speech or participated in a speech therapy program?
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How long and what sounds?
Do/did your parents notice any problems with clarity, mumbling, voice projection, or lack of facial movement?
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Do you have a history of tooth decay, gum disease, gum recession, or gum grafts?
Have you had orthodontic treatment in the past?
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If you have had ortho, what was being treated? (check all that apply)
Have you had any teeth extracted?
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Have you noticed your teeth have shifted or changed?
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Do you snore?
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Average hours of sleep per night?
Do you wake up feeling rested and refreshed?
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Are you tired during the day or do you feel chronically run down or fatigued?
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Have you been tested for Sleep Apnea?
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If yes, when and what was the diagnosis? (AHI: RDI: Oxygen Desaturation)
Do you have a C-Pap or dental sleep appliance?
Yes
No
Cpap
Dental Sleep appliance
Do you wear it?
Have you ever been diagnosed with ADHD?
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Have you ever had symptoms of hyperactivity, trouble focusing, or behavioral issues?
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Did you or do you wet the bed frequently?
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Do you experience restless sleep with frequent tossing and turning?
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Other thoughts or comments
Thank you for taking the time to fill out the questionnaire. We will get back to you soon with your recommendations. 

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