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 *
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Name *
Your answer
Parents Name (if client is under 18 years old)
Your answer
Phone number *
Your answer
Gender *
Date of Birth *
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Specialist(s) - please list all (eg. Orthodontist ENT etc.)
Your answer
Occupation
Your answer
What do you hope to achieve by having Myofunctional Therapy? *
Your answer
Have you ever had a myofunctional therapy assessment before? If so, when? Please also list practitioner(s). *
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). *
Your answer
What is your most difficult problem at home (eg. swallowing, eating, drinking, breathing, speech)? *
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? *
If you answered 'no' to the above question then who may we thank for referring you?
Your answer
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.
Your answer
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