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.
* Required
Email address
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Your email
Today's date
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MM
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DD
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YYYY
Name
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Your answer
Parents Name (if client is under 18 years old)
Your answer
Phone number
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Your answer
Gender
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Female
Male
Gender Neutral
Other:
Date of Birth
*
MM
/
DD
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YYYY
Specialist(s) - please list all (eg. Orthodontist ENT etc.)
Your answer
Occupation
Your answer
What do you hope to achieve by having Myofunctional Therapy?
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Your answer
Have you ever had a myofunctional therapy assessment before? If so, when? Please also list practitioner(s).
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Your answer
Have you ever received any other evaluation or therapy regarding speech, swallowing or breathing (eg. asthma)? If so, when? Please also list practitioner(s).
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Your answer
What is your most difficult problem at home (eg. swallowing, eating, drinking, breathing, speech)?
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Your answer
Please list any allergies (food/environmental) and if it/they are anaphylactic or not?
Your answer
Are you an existing Soni Dentistry client?
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Yes
No
Other
If you answered 'no' to the above question then who may we thank for referring you?
Your answer
Health History (check all that apply)
Acid reflux, heartburn, 'vomy' burps, bad taste in mouth etc.
Anxiety and or Depression
Blood sugar imbalances (experience being 'hangry' regularly)
Bowel movements: Constipation, diarrhea, holding in bowel movements
Crohn's, IBS or both
Digestive concerns: Gas, bloating, stomach pains etc.
Ears: Ear infection(s), pain in ear
Enlarged adenoids/removed adenoids
Enlarged tonsils/tonsillitis/removed tonsils
Excessive thirst
Fingernails: Brittle, up & down lines, white dots, pits etc.
Frequent colds, persistent cough, persistent sore throats, sinusitis etc.
Headaches, affected by pressure changes and/or head injury
High or low blood pressure
High or low cholesterol
Increased weight gain
Lungs: Asthma, regular bronchitis etc.
Mood imbalances
Nose: Nosebleeds, deviated septum, nose surgery
Poor weight gain
Pre Diabetic or Diabetic
Seizures
Feeding (history) birth & infancy - Please fill out for yourself or your child (check all that apply)
Breastfed
Breastfeeding: Falling asleep at breast, gagging, milk leakage, painful nursing and/or supply concerns
Bottlefed (breastmilk or formula)
Daily sippy cup use
Gas, colic and/or regular hiccups
Infant/toddler: Picky eating (types of foods, textures etc.)
Support: Eg. lactation consultant, speech language pathologist, occupational/physical therapist etc.
Feeding (current) - Please fill out for yourself or your child (check all that apply)
Choking/gagging - liquids or solids
Current: Picky/selective eating
Difficulty chewing
Difficulty swallowing
Fast, messy or noisy eater
Large bites
Slow eater and/or takes small bites
Tire easily when eating (eg. apple, dried fruit, nuts etc.)
Dietary (check all that apply)
Caffeinated beverage daily (regular coffee, latte, cappuccino, black tea, green tea etc.)
Craves dairy
Diet: Happy with your current diet
Diet: Unhappy with your current diet
Drink 0-4 glasses of water per day
Drink 5-8+ glasses of water per day
Meat eater
Snacks daily (granola bars, crackers, cookies, chocolate, chips, pastries etc.)
Vegetarian or vegan
Dental History - Past or present (check all that apply)
Bad taste in mouth or Halitosis (unfavourable breath)
Frenum: Lip tie/ lip tie release AND/OR Tongue tie/ tongue tie release
Gingival tissue (gums): Sensitivity, receding, grafting (gum surgery)
Jaw: Pain, clicking, cracking or limited movement (opening, closing or side to side) etc.
Orthodontics (braces or appliances)
Orthognathic surgery (corrective jaw surgery)
Teeth/tooth: Sensitivity, cavities, excessive wear, loss etc.
Wear night guard
Oral(+) Habits - Past or present (check all that apply)
Grinding or Clenching
Clothes, blankets or object chewing, sucking and/or licking (eg. daily gum chewing, lip licking etc.)
Drooling
Thumb, finger and/or tongue sucking
Lip or nail biting
Low sitting tongue (tongue resting on floor of mouth)
Mouth breathing - daytime, nighttime or both
Pacifier use
Throat clearing - at mealtime or in-between meals
Tongue thrust (tongue pushing against front teeth)
Play a musical instrument (eg. clarinet, saxophone etc.)
Sleep History - Past or present (check all that apply)
Back sleeper
Side or stomach sleeper
Frequent bed wetting
Frequent wake ups - drink of water, bathroom trips, children, generally around 3-4am etc.
Gasping for air/choking in the night
Heavy breathing and/or snoring
Heavy sleeper
Night sweating (increased warmth in the night)
Restless and or light sleeper
Sleep 3-5 hours/night
Sleep 6-8+ hours/night
Tired during the day
Females - Past or present (check all that apply)
Birth control - Pill, IUD or other
Cravings - Eg. salt, high fats, carbs, chocolate etc.
Experience breakouts (pimples, blemishes)
Experienced menopause (no longer have a period)
Heavy menstrual period
Irregular cycle
Light menstrual period
Moderate - severe cramping during menstrual cycle
Mood imbalances
Additional information: Tell us any additional information you feel would be important for us to know.
Your answer
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