Long Island Speech Screener Questionnaire
Select which Speech Screener you would like to take:
*
Speech and Language
Tongue Thrust*
Picky Eater
Tongue Tie/Lip Tie**
*A tongue thrust is an abnormal, anterior motion and/or placement of the tongue at rest, when speaking, and when swallowing. A tongue thrust can cause articulation errors, chewing/swallowing difficulties, dietary restrictions, and/or problems with the teeth. A tongue thrust can also contribute to temporomandibular joint disorder and/or sleep apnea in adults.
**A tongue tie, or a short lingual frenum, is when the band of tissue or “string” under your tongue is restricted or shorter/thicker than it should be. A lip tie, or a short labial frenum, can appear under your upper lip or under your lower lip, in which the band of tissue or “string” under the lip is shorter or more restricted than it should be. A tongue and lie tie can affect the way an individual eats, speaks, swallows, and breastfeeds.
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Select the age of the patient
*
Birth-3 months
4-6 Months
7-12 Months
1-2 Years Old
2-3 Years old
3-4 Years old
4-5 Years Old
5-6 Years Old
6-7 Years old
8-10 Years old
11-14 Years old
Highschool Age
Adult
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Birth-3 Month Assessment
Does your baby make cooing sounds?
*
Yes
No
Does your baby’s cry change for different needs?
*
Yes
No
Does your baby smile reflexively and at people?
*
Yes
No
Does your baby become startled by loud sounds?
*
Yes
No
Does your baby become quiet or smile when you talk to her/him?
*
Yes
No
Does your baby soothe/calm when hearing your voice and appear to recognize your voice?
*
Yes
No
Does your baby appear relaxed when feeding, without arching their back or stiffening when feeding?
*
Yes
No
Does your baby appear content during feeding, without crying or fussing during feedings?
*
Yes
No
Does your baby have difficulty latching during breast or bottle feeding?
*
Yes
No
Have you had to trial a variety of formulas with your baby?
*
Yes
No
Have you had to trial a variety of bottles/nipples with your baby?
*
Yes
No
Does your baby feed in a timely manner, without taking a long time to feed?
*
Yes
No
Does your child appear to spit up excessively or have a diagnosis of reflux?
*
Yes
No
Did your infant pass his/her newborn hearing screening?
*
Yes
No
Additional comments/concerns
Your Score
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4-6 Months Assessment
Does your baby coo and babble when playing alone or with you?
*
Yes
No
Does your baby make speech-like babbling sounds, like pa, ba, and mi?
*
Yes
No
Does your baby giggle and laugh?
*
Yes
No
Does your baby make sounds when happy or upset?
*
Yes
No
Does your baby explore through vocal play such as growling, squealing, yelling, making ‘raspberries’?
*
Yes
No
Does your baby move his/her eyes in the direction of sounds?
*
Yes
No
Does your baby raise his/her arms when a parent reaches toward the child?
*
Yes
No
Does your baby respond to changes in your tone of voice?
*
Yes
No
Does your baby notice toys that make sounds?
*
Yes
No
Does your baby pay attention to music?
*
Yes
No
Does your baby put his/her hands on the breast or bottle when feeding?
*
Yes
No
Does your baby bring his/her hands to their mouth?
*
Yes
No
Is your baby accepting spoon feedings?
*
Yes
No
Has your baby started accepting a straw or open cup with support?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Additional comments/concerns
Score
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7-12 Month Assessment
Does your baby babble in long strings of varied sounds, like ‘mimi upup babababa?’
*
Yes
No
Does your baby use sounds and gestures to gain and keep one’s attention?
*
Yes
No
Does your child point to objects and show them to others?
*
Yes
No
Does your child use gestures like waving bye, reaching for “up,” and shaking his head no?
*
Yes
No
Does your child imitate different speech sounds?
*
Yes
No
Does your child say 1 or 2 words, like hi, dog, dada, mama, uh-oh?
*
Yes
No
Does your child turn and look in the direction of a sound?
*
Yes
No
Does your child look when you point?
*
Yes
No
Does your child turn when you call his/her name?
*
Yes
No
Does your child understand words for common items and people - words like cup, truck, juice, and daddy?
*
Yes
No
Does your child start to respond to simple words and phrases like “no,” “come here,” and “want more?”
*
Yes
No
Does your child plays games with you, like peek-a-boo and pat-a-cake?
*
Yes
No
Does your child listen to songs and stories for a short time?
*
Yes
No
Does your child attempt to spoon feed him or herself?
*
Yes
No
Does your child hold a cup with both hands?
*
Yes
No
Does your child accept mashed and harder/lumpier textures?
*
Yes
No
Does your child close the lips to clear the spoon?
*
Yes
No
Does your child accept finger foods?
*
Yes
No
Does your child begin to self-feed with finger foods?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Additional comments/concerns
Score1
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1-2 years old Assessment
Does your child’s vocabulary appear to be increasing and expanding regularly?
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Yes
No
Does your child correctly use sounds such as p, b, h, and w in words?
*
Yes
No
Does your child start to name pictures in books?
*
Yes
No
Does your child ask questions, like “What’s that?”, “Who’s that?”, and “Where’s daddy?”
*
Yes
No
Does your child raise his/her intonation/inflection when asking a question?
*
Yes
No
Does your child put two words together, like “more water,” “no bed,” and “mommy ball” (by 18-24 months)?
*
Yes
No
Can your child point to a few body parts when asked?
*
Yes
No
Does your child follow 1-step directions, like “Bounce the ball” or “Kiss mommy”?
*
Yes
No
Does your child respond to simple questions, like “Who’s that?” or “Where’s your ball?”
*
Yes
No
Does your child listen to simple songs, stories, and rhymes?
*
Yes
No
Does your child point to pictures in a book when you name them?
*
Yes
No
Does your child eat a variety of different foods?
*
Yes
No
Are solid foods your child’s primary nutrition source?
*
Yes
No
Does your child self feed most of the time?
*
Yes
No
Does your child chew with their mouth closed?
*
Yes
No
Does your child present with more control during open cup drinking?
*
Yes
No
Does your child drink from a straw cup?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Has your child ever been evaluated or received Early Intervention services in the past privately or through the county?
*
Yes
No
Additional comments/concerns
score2
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2-3 years old assessment
Does your child have a word for almost everything?
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Yes
No
Does your child talk about things that are not in the room?
*
Yes
No
Does your child use sounds k, g, f, t, d, and n in words?
*
Yes
No
Does your child use words like in, on, and under?
*
Yes
No
Does your child use two- or three- words to talk about and ask for things?
*
Yes
No
Is your child understood by people who know him/her?
*
Yes
No
Does your child ask “Why?”
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Yes
No
Does your child put 3 words together to talk about things?
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Yes
No
Does your child understand opposites, like go-stop, big-little, and up-down?
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Yes
No
Does your child follow 2-step directions, like “Get the ball and put it in the bucket.”
*
Yes
No
Does your child understand new words quickly?
*
Yes
No
Does your child ask wh-questions and yes/no questions?
*
Yes
No
Does your child raise his/her intonation/inflection when asking a question?
*
Yes
No
Does your child appear to become frustrated when they are not understood?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing food, or spitting out food?
*
Yes
No
Does your child speak fluently without repetitions or stuttering present?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Has your child ever been evaluated or received Early Intervention services in the past privately or through the county?
*
Yes
No
Additional comments/concerns
score3
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3-4 years old assessment
Does your child answer simple who, what, and where questions?
*
Yes
No
Does your child use rhyming words, like mat-hat?
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Yes
No
Does your child use pronouns, like I, you, me, we, and they?
*
Yes
No
Does your child use some plural words, like toys, birds, and dogs?
*
Yes
No
Do most people understand what your child says?
*
Yes
No
Does your child ask how and when questions?
*
Yes
No
Does your child put 4 words together, though may make some mistakes? For example, ‘I goed to the park.’
*
Yes
No
Does your child talk about what happened during the day, using about 4 sentences at a time?
*
Yes
No
Does your child respond when you call from another room?
*
Yes
No
Is your child able to identify and label colors like, red, blue, and green?
*
Yes
No
Does your child identify and label some shapes, like circle, heart, square?
*
Yes
No
Does your child engage in imaginative play, such as cooking in a toy kitchen, treating a baby boll as a real baby?
*
Yes
No
Does your child raise his/her intonation/inflection when asking a question?
*
Yes
No
Does your child understand words for family members, like brother, grandmother, and aunt?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing food, or spitting out food?
*
Yes
No
Does your child speak fluently without repetitions or stuttering present?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Has your child ever been evaluated or received services privately or through CPSE?
*
Yes
No
Additional comments/concerns
score4
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4-5 Year old assessment
Does your child say most speech sounds correctly?
*
Yes
No
Does your child delete the final sound in words (‘ca’ for ‘cat’)?
*
Yes
No
Does your child respond to “What did you say?”
*
Yes
No
Does your child name letters and numbers?
*
Yes
No
Does your child use sentences that have more than 1 action word, like jump, play, and get. Though they may make some mistakes, like “Zach gots 2 candy, but I got one.”
*
Yes
No
Does your child tell short stories?
*
Yes
No
Is your child able to have a longer conversation with others?
*
Yes
No
Does your child change the way they speak, depending on the listener and place? For example, your child might use short sentences with younger children or may talk louder outside than inside.
*
Yes
No
Does your child understand words for order, like first, next, and last?
*
Yes
No
Does your child understand words for time, like yesterday, today, and tomorrow?
*
Yes
No
Does your child follow longer directions, like “Put your pajamas on, brush your teeth, and then pick out a book.”?
*
Yes
No
Does your child follow classroom directions, like “Draw a circle on your paper around something you eat.”?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing, or spitting out the food?
*
Yes
No
Does your child speak fluently without repetitions or stuttering?
*
Yes
No
Does your child demonstrate appropriate eye contact when speaking or listening to others?
*
Yes
No
Can your child initiate and/or maintain a conversation for multiple exchanges?
*
Yes
No
Does your child appropriately share and take turns when playing with peers?
*
Yes
No
Can your child attend to a task for a short period of time?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Has your child ever been evaluated or received services privately or through CPSE?
*
Yes
No
Additional comments/concerns
score5
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5-6 years old assessment
Does your child recognize and label colors and basic shapes?
*
Yes
No
Can your child identify and label the letters of the alphabet ?
*
Yes
No
Does your child know the sounds associated with each letter of the alphabet?
*
Yes
No
Does your child recite their name, address, and phone number?
*
Yes
No
Does your child understand basic concepts regarding print, like knowing which way the pages go and that words are read left to right and top to bottom?
*
Yes
No
Does your child know that a story has a beginning, middle and end?
*
Yes
No
Does your child remain on an activity for 15 minutes and finish a short assignment?
*
Yes
No
Does your child respond appropriately when told ‘no’ or when told to do something they may not want to do?
*
Yes
No
Does your child make plans about how to play, what to build, or what to draw?
*
Yes
No
Does your child use words to argue and try to reason with people?
*
Yes
No
Does your child properly use most plurals and pronouns?
*
Yes
No
Does your child tell stories, jokes, and riddles?
*
Yes
No
Does your child understand stories, jokes, and riddles?
*
Yes
No
Does your child talk about and understand opposites and compare items using opposites, like “This purple ball is bigger than the orange ball.”?
*
Yes
No
Does your child use past and present verb tenses correctly to talk about events that have happened or will happen?
*
Yes
No
Does your child follow multi-step directions?
*
Yes
No
Does your child understand why it is helpful to share and get along with other children of the same age?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing, or spitting out the food?
*
Yes
No
Does your child speak fluently without repetitions or stuttering?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Has your child ever been evaluated or received services privately or through the school district?
*
Yes
No
Additional comments/concerns
score6
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6-7 Years old assessment
Is your child developing the skills to reason and think logically?
*
Yes
No
Is your child able to learn from what he/she hears?
*
Yes
No
Is your child able to learn from what he/she reads?
*
Yes
No
Can your child sound out words?
*
Yes
No
Does your child have a good sense of time, understanding increments of time, days, weeks, months, and seasons?
*
Yes
No
Does your child understand the relationship between letters and sounds?
*
Yes
No
Does your child know, use, and understand thousands of words?
*
Yes
No
Does your child use language to express feelings, persuade others, tell stories, and tell jokes/riddles?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing, or spitting out food?
*
Yes
No
Does your child speak fluently without repetitions or stuttering?
*
Yes
No
Does your child understand why it is helpful to share and get along with other children of the same age?
*
Yes
No
Does your child have a history of ear infections or suffer from chronic ear fluid?
*
Yes
No
Is your child able to express ideas with written language?
*
Yes
No
Has your child ever been evaluated or received services privately or through the school district?
*
Yes
No
Additional comments/concerns
score7
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8-10 Years old assessment
Is your child intelligible and understood by strangers, friends, and family?
*
Yes
No
Are your child’s utterances grammatically correct the majority of the time?
*
Yes
No
Is your child social amongst peers?
*
Yes
No
Does your child take multiple perspectives and understand different points of view?
*
Yes
No
Does your child have the language skills necessary to gather information and formulate well-organized opinions and thoughts?
*
Yes
No
Does your child often misarticulate sounds in words when speaking?
*
Yes
No
Does your child present with any academic difficulties in the areas of reading, writing, spelling, and/or comprehension?
*
Yes
No
Is your child on or above grade level for all academic subjects?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing, or spitting out food?
*
Yes
No
Does your child speech fluently without repetitions or stuttering?
*
Yes
No
Can your child attend to a task for a prolonged period of time?
*
Yes
No
Has your child ever been evaluated or received services privately or through the school district?
*
Yes
No
Additional comments/concerns
score8
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11-14 Years old
Does your child present with an extensive and evolving vocabulary?
*
Yes
No
Does your child understand irony and sarcasm?
*
Yes
No
Does your child use and understand complex grammatical structures?
*
Yes
No
Does your child use language functionally and adjust their choice of words depending on context and/or audience (ie speak differently to friends versus speaking to a teacher)?
*
Yes
No
Does your child contribute to conversations and maintain a topic?
*
Yes
No
Does your child support his/her opinion to formulate an argument?
*
Yes
No
Does your child present with any academic difficulties in the areas of reading, writing, spelling, and/or comprehension?
*
Yes
No
Is your child on or above grade level for all academic subjects?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing, or spitting out food?
*
Yes
No
Does your child speak fluently without repetitions or stuttering?
*
Yes
No
Has your child ever been evaluated or received services privately or through the school district?
*
Yes
No
Additional comments/concerns
score9
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High School Age assessment
Does your child appear to present with more mature thinking skills and set goals for the future?
*
Yes
No
Does your child demonstrate an increased ability to reason, make educated guesses, and understand fact from fiction?
*
Yes
No
Does your child think about topics in a more abstract way?
*
Yes
No
Does your child demonstrate reasoning skills and attempt to find solutions to conflict?
*
Yes
No
Does your child manage time effectively?
*
Yes
No
Does your child follow long and complicated instructions with many different directions?
*
Yes
No
Does your child understand figurative language, make predictions, and understand sarcasm?
*
Yes
No
Does your child tell long and complex stories?
*
Yes
No
Does your child tell stories that are interesting and engaging to the listener?
*
Yes
No
Does your child use language to persuade and negotiate with people?
*
Yes
No
Does your child present with any academic difficulties in the areas of reading, writing, spelling, and comprehension?
*
Yes
No
Is your child on or above grade level for all academic subjects?
*
Yes
No
Does your child accept most foods offered as part of a family meal?
*
Yes
No
Does your child accept foods without gagging, pocketing food, or spitting out food?
*
Yes
No
Does your child speech fluently without repetitions or stuttering present?
*
Yes
No
Has your child ever been evaluated or received services privately or through the school district?
*
Yes
No
Additional comments/concerns
score10
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Adult assessment
Are you (or your loved one) able to name items without hesitation or delay?
*
Yes
No
Do you (or your loved one) read articles and books with ease and able to recall and retell details from the written material?
*
Yes
No
Are you (or your loved one) able to eat foods of all textures/consistencies without coughing or difficulty?
*
Yes
No
Are you (or your loved one) able to drink liquids without coughing or difficulty?
*
Yes
No
Do you (or your loved one) speak fluently without repetitions or stuttering?
*
Yes
No
Are you (or your loved one) understood by others 100% of the time?
*
Yes
No
Can you (or your loved one) move your lips, tongue, and jaw on command to a desired position?
*
Yes
No
Do you (or your loved one) understand what others are saying?
*
Yes
No
Can you (or your loved one) share thoughts with ease?
*
Yes
No
Do you (or your loved one) speak at an appropriate rate, not too slow and not too fast?
*
Yes
No
Do you (or your loved one) speak at an appropriate volume, not too loud and not too low?
*
Yes
No
Do you (or your loved one) have an appropriate vocal quality, without the voice sounding hoarse, strained, or raspy?
*
Yes
No
Are you (or your loved one) able to make plans and set goals?
*
Yes
No
Do you (or your loved one) have the sensation of a lump in your throat?
*
Yes
No
Does your (or your loved ones) voice feel tired at the end of a day?
*
Yes
No
Do you (or your loved one) suffer from temporomandibular joint disorder (TMJD)?
*
Yes
No
Do you (or your loved one) suffer from sleep apnea?
*
Yes
No
Do you (or your loved one) feel your tongue resting low in the mouth or against your teeth?
*
Yes
No
Additional comments/concerns
score11
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Select age of Patient
Is the patient a:
*
Child
Adult
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Child Tongue Thrust Assessment
Does your child have any trouble producing any of the following sounds: s, z, sh, ch, r, “j” as in ‘juice’ “ge” as in ‘beige,’ or “zh” as in mea“su”re?
*
Yes
No
Do you see your child’s tongue when they are speaking or when swallowing?
*
Yes
No
Does your child rest with their mouth open and/or their tongue forward?
*
Yes
No
Does your child sleep with their mouth open?
*
Yes
No
Does your child eat at a rapid rate or a very slow rate?
*
Yes
No
Is your child a picky eater?
*
Yes
No
Does your child tend to be a messy eater?
*
Yes
No
Does your child drink excessively when eating?
*
Yes
No
Does your child tend to pool and/or drool saliva?
*
Yes
No
Does your child present with grinding, popping, or clenching of their jaw?
*
Yes
No
Do you have any concerns regarding your child’s teeth?
*
Yes
No
Following the loss of your child’s “baby teeth” have you noticed that it has taken a long time for the adult teeth to come in?
*
Yes
No
Has anyone ever told you your child has a short lingual frenum/tongue tie?
*
Yes
No
Did your child use a bottle or pacifier and/or suck their thumb/finger beyond 12 months of age?
*
Yes
No
Does your child currently present with any type of oral fixation such as mouthing objects, tongue sucking, nail biting, thumb/finger sucking, excessive lip licking/lip biting?
*
Yes
No
Does your child have difficulties swallowing pills?
*
Yes
No
Does your child avoid certain food textures or consistencies?
*
Yes
No
Additional comments/concerns
score12
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Adult Tongue Thrust Assessment
Does your tongue rest against your teeth?
*
Yes
No
When you swallow, do you feel your tongue make contact with your teeth?
*
Yes
No
Do you suffer from temporomandibular joint (TMJ) disorder or have pain in your TM joint?
*
Yes
No
Do you suffer from sleep apnea?
*
Yes
No
If you swallow with your lips open, can you see your tongue pushing forward at all?
*
Yes
No
Have you had braces, yet feel your teeth have shifted?
*
Yes
No
Have you ever had speech therapy?
*
Yes
No
Did you, or do you, have trouble producing any of the following sounds: s, z, sh, ch, r, “j” as in ‘juice,’ “ge” as in ‘beige’ or or “zh” as in mea“su”re?
*
Yes
No
Do you have any difficulties sitting with your lips closed and breathing through your nose?
*
Yes
No
Do you feel you are a mouth breather?
*
Yes
No
Do you feel you drink excessively when eating?
*
Yes
No
Do you currently present with any type of oral fixation such as mouthing objects, tongue sucking, nail biting, excessive lip licking/lip biting?
*
Yes
No
Do you have difficulties swallowing pills?
*
Yes
No
Do you avoid certain food textures or consistencies?
*
Yes
No
Do you present with grinding, popping, or clenching of your jaw?
*
Yes
No
Additional comments/concerns
score13
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Picky Eater Assessment
Are you concerned that you or your family member avoids certain food textures or consistencies?
*
Yes
No
Are you concerned that you or your family member drinks excessively when eating?
*
Yes
No
Are you concerned that you or your family member does not meet the required amount of calorie intake daily?
*
Yes
No
Are you concerned that you or your family member does not eat enough foods within each food group on a daily basis?
*
Yes
No
Are you concerned that you or your family member gags when touching, smelling, or trying certain foods?
*
Yes
No
Are you or your family member losing weight or considered failure to thrive?
*
Yes
No
Is your or your loved one’s diet limited to mostly carbohydrates?
*
Yes
No
Are you or your loved one afraid to eat due to a fear of choking?
*
Yes
No
Will you or your child only eat brand specific food items?
*
Yes
No
Additional comments/concerns
score14
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Is this screener for a:
Child
Adult
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Child Tongue Tie/Lip Tie Questionnaire
Does your child present with difficulties being understood by his/her parents?
*
Yes
No
Does your child present with difficulties being understood by outsiders?
*
Yes
No
Does your child present with difficulties speaking fast?
*
Yes
No
Does your child present with difficulties being understood when speaking in longer sentences compared to shorter sentences or single words?
*
Yes
No
Did your child present with a shallow latch or painful breastfeeding?
*
Yes
No
Did your child present with or currently present with poor weight gain?
*
Yes
No
Did your child present with or currently present with reflux or excessive spitting up?
*
Yes
No
Did your child present with or currently present with gassiness as a baby?
*
Yes
No
Did your child present with or currently present with clicking or smacking noise when eating?
*
Yes
No
Did your child present with or currently present with excessive crying and/or colic as a baby?
*
Yes
No
Does your child present with frustration when eating?
*
Yes
No
Does your child or did your child in the past present with difficulty transitioning to solid foods?
*
Yes
No
Is your child a slow eater?
*
Yes
No
Does your child prefer to graze on foods throughout the day rather than eat a full meal?
*
Yes
No
Does your child present with pocketing of food in the cheeks (like a chipmunk)?
*
Yes
No
Does your child present with or ever present with choking or gagging on foods?
*
Yes
No
Does your child present with difficulty or resistance to trying new foods?
*
Yes
No
Does your child sleep in strange positions?
*
Yes
No
Does your child present as a restless sleeper, moving a lot in their sleep?
*
Yes
No
Does your child wake easily and often throughout the night?
*
Yes
No
Does your child wet the bed?
*
Yes
No
Does your child wake up tired and not refreshed?
*
Yes
No
Does your child grind his/her teeth while sleeping?
*
Yes
No
Does your child sleep with his/her mouth open?
*
Yes
No
Does your child snore while sleeping?
*
Yes
No
Does your child gasp for air while sleeping?
*
Yes
No
Does your child present with neck or shoulder pain/tension?
*
Yes
No
Does your child present with TMJ pain, clicking or popping?
*
Yes
No
Does your child suffer from frequent headaches or migraines?
*
Yes
No
Does your child have a strong gag reflex?
*
Yes
No
Does your child, or did your child, present with prolonged thumb sucking or pacifier use?
*
Yes
No
Has your child had his/her tonsils and/or adenoids removed?
*
Yes
No
Does your child, or has your child, suffered from frequent ear infections?
*
Yes
No
Does your child have, or has your child had, ear tubes?
*
Yes
No
Does your child present with hyperactivity or inattention?
*
Yes
No
Does your child suffer from constipation?
*
Yes
No
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Adult Tongue Tie/Lip Tie Questionnaire
Do others have a hard time understanding your speech?
*
Yes
No
Do you experience difficulty speaking fast?
*
Yes
No
Do you experience difficulty getting certain words out?
*
Yes
No
Does your jaw tire when talking or reading aloud?
*
Yes
No
Is your speech harder to understand in long sentences?
*
Yes
No
Are you frustrated when eating?
*
Yes
No
Are you a slow eater?
*
Yes
No
Do you have a small appetite?
*
Yes
No
Do you prefer to graze on foods throughout the day?
*
Yes
No
Do you ever pocket or pack food in your cheeks?
*
Yes
No
Are you picky when it comes to different food textures?
*
Yes
No
Do you have difficulty swallowing pills?
*
Yes
No
Do you ever choke or gag on foods or water?
*
Yes
No
Do you have trouble breathing through your nose?
*
Yes
No
Do you present with an open mouth posture during the day or breath through your mouth?
*
Yes
No
Have your tonsils and/or adenoids been removed?
*
Yes
No
Do you suffer from sinus issues or have had any sinus surgery?
*
Yes
No
Have you had teeth extracted for braces?
*
Yes
No
Have you had jaw surgery in the past?
*
Yes
No
Do you sleep in strange positions?
*
Yes
No
Do you move around a lot at night?
*
Yes
No
Do you wake up easily or often?
*
Yes
No
Do you feel you get a poor quality of sleep?
*
Yes
No
Do you wake up tired and not refreshed?
*
Yes
No
Do you use or have been prescribed a sleep appliance or CPAP machine?
*
Yes
No
Do you grind your teeth while sleeping?
*
Yes
No
Do you sleep with your mouth open?
*
Yes
No
Do you snore while sleeping?
*
Yes
No
Do you gasp for air or stop breathing when sleeping?
*
Yes
No
Do you suffer from neck or shoulder pain or tension?
*
Yes
No
Do you present with TMJ pain, clicking, or popping?
*
Yes
No
Do you suffer from migraines or headaches?
*
Yes
No
Do you present with a strong gag reflex?
*
Yes
No
Did you present with prolonged thumb sucking as a child?
*
Yes
No
Do you or did you suffer from frequent ear infections or require ear tubes as a child?
*
Yes
No
Do you suffer from reflux?
*
Yes
No
Do you suffer from constipation?
*
Yes
No
Do you present with hyperactivity/inattention?
*
Yes
No
Do you feel stressed or suffer from anxiety?
*
Yes
No
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