Child Myofunctional Intake Form

Myofunctional Child Intake Form
Patient Full Name *

First Name Last Name
Date *

Month Day Year
Date
Chief complaint/concern/reason for referral *

Tongue tie Mouth breathing Tongue thrust Thumb sucking Snoring Teeth grinding Teeth clenching Migraines Orthodontic treatment Chewing/feeding/swallowing concerns Speech concerns Sleep apnea or SDB concerns Jaw pain Headaches Oral 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 products Have you been diagnosed with sleep apnea? Previous surgeries Allergies/Sensitivities Depression/Anxiety/Mental Illness Tonsils or adenoids removed? None Of The Above
Child's General Health (Good, Fair or Poor?) *

Good Fair Poor
History of Speech Therapy *

Present Speech Concerns Headaches Migraines Jaw Pain Earaches Ringing in Ears None 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 together Lives with both parents separately
Parent(s) or Guardian(s) names: *

First Name Last 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 difficulties Breathe through your mouth Difficulty breathing through nose Previous nasal surgery Seen an ENT doctor for any reason Frequent sinus colds/sore throats Had a sleep study Wear a CPAP or oral sleep appliance Clenching or grinding teeth Wear or have been told you should wear a Night Guard Wake up with sore jaws or teeth or headaches in morning Snore or breathe loudly during sleep Trouble Falling Asleep Trouble Staying Asleep Wet the bed or use the bathroom during the night Do you feel restless during sleep Sweating in the night Wake up choking/coughing/feeling like you can't breathe Frequent nightmares/sleep walking Wake up with a dry mouth Wake up feeling refreshed or still tired Trouble focusing or paying attention during day Feel fatigued, sleepy or brain fog during day Fall asleep watching tv Often need to nap during the day or fall asleep at school Wake up through the night Feel irritable/angry/short temper Excessive drooling Do 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? *

Yes No
Does your child have dark circles or bags under their eyes? *

Yes No
Digestive/Nutritional Info

Avoidance of certain foods/textures Picky eating Messy eating Fast eating Slow eating Trouble swallowing pills Difficulty chewing and/or swallowing Chewing with mouth open Difficulty breathing and chewing at same time Gas/bloating/burping/ hiccupping/stomach aches after eating Do 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) *

Low Mod High None
Early Childhood
Birth History *

Complications Vaccuum Forceps Preterm C-Section
Breastfed (how long): *
Bottle fed (how long) *
Tube fed (how long) *
Difficulty breast or bottle feeding? *

Yes No
History of reflux *

Yes No
Childhood trauma/injuries *

Yes No
Tongue tie noticed or revised as infant/toddler *

Yes No
Childhood allergies/asthma ? Please list *
Habits (Past or Present)

Thumb sucking Finger sucking Chewing on clothes /blankets/pens/other Nail biting Cheek/lip biting or sucking Lip licking Pacifier Use Other 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? *

Yes No
Should be Empty:

Myofunctional Child Intake Form

Early Childhood