Child Myofunctional Intake Form

Myofunctional Child Intake Form
Patient Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date*

MonthDayYear
Date
Chief complaint/concern/reason for referral*

Tongue tieMouth breathingTongue thrustThumb suckingSnoringTeeth grindingTeeth clenchingMigrainesOrthodontic treatmentChewing/feeding/swallowing concernsSpeech concernsSleep apnea or SDB concernsJaw painHeadachesOral habit Please list or describe any details or concerns you would like us to be aware of:
Please list any healthcare professionals or specialists you have seen or are currently seeing. Please include contact info if I have your permission to contact them if needed:
What other type of therapies have you tried related to your concerns? Have other therapies been successful? Please describe
What do you hope to accomplish with Orofacial Myofunctional Therapy?*
Medical History*

Known medical conditions or diseases (past or present)Current medications (prescription or OTC)Current supplements/natural productsHave you been diagnosed with sleep apnea?Previous surgeriesAllergies/SensitivitiesDepression/Anxiety/Mental IllnessTonsils or adenoids removed?None Of The Above
Child's General Health (Good, Fair or Poor?)*

GoodFairPoor
History of Speech Therapy*

Present Speech ConcernsHeadachesMigrainesJaw PainEarachesRinging in EarsNone Of The Above
How Often you have Headaches and what's the pain level?
How Often you have Migraines?
How Often you have Jaw Pain, What's the pain level and where is the pain?
How Often you have Earaches?
How Often you have Ringing in Ears?
Family History*

Lives with both parents togetherLives with both parents separately
Parent(s) or Guardian(s) names: *

First NameLast Name
Siblings (ages) If applicable:
Family History of orthodontic treatment or concerns (please describe):
Family history of mouth breathing or tongue tie?
Airway/Sleep

Asthma/breathing difficultiesBreathe through your mouthDifficulty breathing through nosePrevious nasal surgerySeen an ENT doctor for any reasonFrequent sinus colds/sore throatsHad a sleep studyWear a CPAP or oral sleep applianceClenching or grinding teethWear or have been told you should wear a Night GuardWake up with sore jaws or teeth or headaches in morningSnore or breathe loudly during sleepTrouble Falling AsleepTrouble Staying AsleepWet the bed or use the bathroom during the nightDo you feel restless during sleepSweating in the nightWake up choking/coughing/feeling like you can't breatheFrequent nightmares/sleep walkingWake up with a dry mouthWake up feeling refreshed or still tiredTrouble focusing or paying attention during dayFeel fatigued, sleepy or brain fog during dayFall asleep watching tvOften need to nap during the day or fall asleep at schoolWake up through the nightFeel irritable/angry/short temperExcessive droolingDo you have any concerns with your child's sleep? (Please explain)
When did you have a sleep study?
Does the Night Guard help or make your problems worse?
When does your child go to bed? *
When does your child wake up for the day? *
Does your child frequently resist going to bed? *
How long does it take your child to fall asleep? *
Have you ever witnessed your child stop breathing during sleep?*

YesNo
Does your child have dark circles or bags under their eyes?*

YesNo
Digestive/Nutritional Info

Avoidance of certain foods/texturesPicky eatingMessy eatingFast eatingSlow eatingTrouble swallowing pillsDifficulty chewing and/or swallowingChewing with mouth openDifficulty breathing and chewing at same timeGas/bloating/burping/ hiccupping/stomach aches after eatingDo you Gag easily
How many cups of water do you drink daily? *
How many cups of caffeinated beverages do you drink daily? *
Sugary foods/beverages intake daily (none, low, mod or high)*

LowModHighNone
Early Childhood
Birth History*

ComplicationsVaccuumForcepsPretermC-Section
Breastfed (how long):*
Bottle fed (how long)*
Tube fed (how long)*
Difficulty breast or bottle feeding?*

YesNo
History of reflux*

YesNo
Childhood trauma/injuries*

YesNo
Tongue tie noticed or revised as infant/toddler*

YesNo
Childhood allergies/asthma ? Please list *
Habits (Past or Present)

Thumb suckingFinger suckingChewing on clothes /blankets/pens/otherNail bitingCheek/lip biting or suckingLip lickingPacifier UseOther habits? Please Explain
Dental/Orthodontic History
Name of the Dentist/Dental Office
When was your last dental visit?
Have you had orthodontic treatment? If Yes, When did you have your treatment?
Orthodontist name?
Palate expander, head gear, or other appliance used?
Do you have retainers (fixed wires or removable retainers)?
Have you noticed relapse? (shifting of teeth, changes to bite, etc)
Have you had any adult teeth extracted?
Any Previous jaw surgery?
Do you have a history of cavities or extensive dental treatment?
Do you have chipped, broken or worn teeth?
Would you like an orthodontic referral?*

YesNo
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Myofunctional Child Intake Form

Early Childhood