Child Assessment

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Child Assessment

Please check all that apply on the following screening form. Generally, if these questions can be applied to your child, they are likely to have some Myofunctional concern. If multiple boxes below are checked, such as two or more, Myofunctional therapy is most likely recommended. This form can be used as a basis for an exam and allow us to focus on any specific symptoms you are experiencing.

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Please select the boxes below where you are experiencing symptoms:

Do you notice that your child occasionally has their mouth open at rest?

Do you notice that your child sleeps with his or her mouth open?

Did your child have difficulties feeding as an infant?

Has anyone ever told you that your child may be tongue tied?

Does your child snore or grind their teeth?

Has your child ever had a thumb or finger sucking habit?

Are you noticing that your child’s teeth are erupting crooked?

Has your child ever had troubles with speech, or been in a speech therapy program?

Has your child experienced any issues with digestion? ( stomach aches, burping, gas, or acid reflux)

Do you notice that your child has a hyper-active gag reflex?

Does your child have difficulty swallowing pills?

Does is seem like your child is a messy eater? ( chews with mouth open, drinks and chews at the same

Has your child experienced any breathing issues or difficulties? (chronic congestion, asthma, seasonal allergies)

Has your child had their tonsils removed, or have you been told the tonsils are enlarged?

Please contact us for an evaluation at @ myomattersqc@gmail.com or contact us through our website at www.myomatters.com

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