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.
Question 1 of 9
Breathing
Mouth Breathing
Stuffy Nose
Bad Breath
Allergies
Asthma
Frequent Ear Infections
Frequent Upper Respiratory Infections
Frequent Bronchitis/Pneumonia
Frequent Strep Throat
Question 2 of 9
Pain
Facial Pain
Headaches
Migraines
Neck Pain
TMJ Pain
Toothache
Question 3 of 9
Oral Habits
Clenching
Grinding
Pacifier Use
Thumb Sucking/Digit Sucking
Lip Licking
Nail Biting
Tongue Sucking
Pica
Question 4 of 9
Eating Behavior/ Digestive Issues
Chewing with mouth open
Messy Eating
Loud Chewing
Takes a long time to eat
Eats too quickly
Very selective eater
Doesn't like certain textures
Chokes easily
Gags easily
Needs liquids to wash food down during meals
Swallowing difficulty
Frequent belching/swallowing air
Vomiting after meals
Consipation
Acid reflux
Question 5 of 9
Speech Difficulty
Speech Erros
Speech Delay
Mumbled Speech
Difficult to Understand
Stutters
Raspy Voice
Question 6 of 9
Oral Ties (Do you believe the patient currently presents with oral ties?)
Tongue-Tie
Lip Tie
Buccal/Cheek Ties
Not sure
Previous Release
Question 7 of 9
Other Patient/Parent Concerns
Trouble Focusing
Behavior Issues
Brain Fog or Forgetfulness
Hyperactivity
Injury/Trauma
Low muscle tone
Poor academic performance
Suspects ADD or ADHD
Question 8 of 9
Sleep Questionnaire
Back sleeper
Side sleeper
Stomach Sleeper
Restless Sleep - Frequent tossing and turning
Talks during sleep
Dreams often
No dreams
Night Terrors
Sleep walking
Audible/Loud Breathing
Snoring
Sleep Apnea Diagnosis
Sleep Apnea Suspected - Gasps for air
Daytime Sleepiness
Exhausted during the day
Drooling during sleep
Enuresis - Bed wetting
Nocturia - Waking up multiple times to use the bathroom
Nighttime sweating
Insomnia
Need for melatonin
Need for sleep aids
Difficult to wake up in the morning
Sleep paralysis
Teeth Grinding
Uneventful
Question 9 of 9
Phone Number - For our team to call you