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Myofunctional Therapy Assessment

Find out if you could benefit from Orofacial Myofuncitonal Therapy

This quiz is not medical advice. Please speak to your doctor or specialist prior to taking medical action.

Start

Question 1 of 9

Breathing

(Select all that apply)
A

Mouth Breathing

B

Stuffy Nose

C

Bad Breath

D

Allergies

E

Asthma

F

Frequent Ear Infections

G

Frequent Upper Respiratory Infections

H

Frequent Bronchitis/Pneumonia

I

Frequent Strep Throat

Question 2 of 9

Pain

(Select all that apply)
A

Facial Pain

B

Headaches

C

Migraines

D

Neck Pain

E

TMJ Pain

F

Toothache

Question 3 of 9

Oral Habits

(Select all that apply)
A

Clenching

B

Grinding

C

Pacifier Use

D

Thumb Sucking/Digit Sucking

E

Lip Licking

F

Nail Biting

G

Tongue Sucking

H

Pica

Question 4 of 9

Eating Behavior/ Digestive Issues

(Select all that apply)
A

Chewing with mouth open

B

Messy Eating

C

Loud Chewing

D

Takes a long time to eat

E

Eats too quickly

F

Very selective eater

G

Doesn't like certain textures

H

Chokes easily

I

Gags easily

J

Needs liquids to wash food down during meals

K

Swallowing difficulty

L

Frequent belching/swallowing air

M

Vomiting after meals

N

Consipation

O

Acid reflux

Question 5 of 9

Speech Difficulty

(Select all that apply)
A

Speech Erros

B

Speech Delay

C

Mumbled Speech

D

Difficult to Understand

E

Stutters

F

Raspy Voice

Question 6 of 9

Oral Ties (Do you believe the patient currently presents with oral ties?)

(Select all that apply)
A

Tongue-Tie

B

Lip Tie

C

Buccal/Cheek Ties

D

Not sure

E

Previous Release

Question 7 of 9

Other Patient/Parent Concerns

(Select all that apply)
A

Trouble Focusing

B

Behavior Issues

C

Brain Fog or Forgetfulness

D

Hyperactivity

E

Injury/Trauma

F

Low muscle tone

G

Poor academic performance

H

Suspects ADD or ADHD

Question 8 of 9

Sleep Questionnaire

(Select all that apply)
A

Back sleeper

B

Side sleeper

C

Stomach Sleeper

D

Restless Sleep - Frequent tossing and turning

E

Talks during sleep

F

Dreams often

G

No dreams

H

Night Terrors

I

Sleep walking

J

Audible/Loud Breathing

K

Snoring

L

Sleep Apnea Diagnosis

M

Sleep Apnea Suspected - Gasps for air

N

Daytime Sleepiness

O

Exhausted during the day

P

Drooling during sleep

Q

Enuresis - Bed wetting

R

Nocturia - Waking up multiple times to use the bathroom

S

Nighttime sweating

T

Insomnia

U

Need for melatonin

V

Need for sleep aids

W

Difficult to wake up in the morning

X

Sleep paralysis

Y

Teeth Grinding

Z

Uneventful

Question 9 of 9

Phone Number - For our team to call you

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