Myofunctional Child Intake Form
Patient Full Name
Please enter a valid phone number.
Chief complaint/concern/reason for referral
Sleep apnea or SDB concerns
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?
Known medical conditions or diseases (past or present)
Current medications (prescription or OTC)
Current supplements/natural products
Have you been diagnosed with sleep apnea?
Tonsils or adenoids removed?
None Of The Above
Child's General Health (Good, Fair or Poor?)
History of Speech Therapy
Present Speech Concerns
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?
Lives with both parents together
Lives with both parents separately
Parent(s) or Guardian(s) names:
Siblings (ages) If applicable:
Family History of orthodontic treatment or concerns (please describe):
Family history of mouth breathing or tongue tie?
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
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?
Does your child have dark circles or bags under their eyes?
Avoidance of certain foods/textures
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)
Breastfed (how long):
Bottle fed (how long)
Tube fed (how long)
Difficulty breast or bottle feeding?
History of reflux
Tongue tie noticed or revised as infant/toddler
Childhood allergies/asthma ? Please list
Habits (Past or Present)
Chewing on clothes /blankets/pens/other
Cheek/lip biting or sucking
Other habits? Please Explain
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?
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?
Should be Empty: