Myofunctional Therapy Intake Form
Please answer the following questions as truthfully as possible for yourself or your child. We will further clarify your answers at your consultation appointment.
Email address *
Today's date *
MM
/
DD
/
YYYY
Name *
Parents Name (if client is under 18 years old)
Phone number *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Specialist(s) - please list all (eg. Orthodontist ENT etc.)
Occupation
What do you hope to achieve by having Myofunctional Therapy? *
Have you ever had a myofunctional therapy assessment before? If so, when? Please also list practitioner(s). *
Have you ever received any other evaluation or therapy regarding speech, swallowing or breathing (eg. asthma)? If so, when? Please also list practitioner(s). *
What is your most difficult problem at home (eg. swallowing, eating, drinking, breathing, speech)? *
Please list any allergies (food/environmental) and if it/they are anaphylactic or not?
Are you an existing Soni Dentistry client? *
If you answered 'no' to the above question then who may we thank for referring you?
Health History (check all that apply)
Feeding (history) birth & infancy - Please fill out for yourself or your child (check all that apply)
Feeding (current) - Please fill out for yourself or your child (check all that apply)
Dietary (check all that apply)
Dental History - Past or present (check all that apply)
Oral(+) Habits - Past or present (check all that apply)
Sleep History - Past or present (check all that apply)
Females - Past or present (check all that apply)
Additional information: Tell us any additional information you feel would be important for us to know.
Submit
Never submit passwords through Google Forms.
This form was created inside of Alive Learning. Report Abuse