Orofacial Myofunctional Therapy Health History Questionnaire
Please fill out the questionnaire for yourself or for your child.
This survey includes questions from the following catagories:
- Early Childhood History
- Speech
- Digestion
- Orthodontic and Dental History
- Head, Neck, and Jaw Pain
- Sleep
This is a comprehensive survey and takes about 10 minutes to complete.
This survey is being filled out for:
Please enter you or your child's name below
How were you fed as a baby?
Any difficulty with your latch during breastfeeding?
Please describe any difficulty with breastfeeding
Premature birth?
Long difficult Labor?
C-Section?
Tongue tied or lip tied as an infant?
If yes, were ties released or are they still present?
History of ear problems or infections?
Tubes placed in ears?
Current ear infection problems?
History of hyperactivity? Signs or symptoms of attention deficit disorder? Trouble paying attention?
Select all the following habits that apply:
Have you been evaluated by a speech language pathologist?
If treated, what was the focus of speech therapy?
Do you believe there are any current speech concerns?
If so, what are they?
Select all of the following that apply:
Digestive problems
What is the frequency of your symptoms?
If you do not deal with digestive symptoms, or are unsure, select N/A.
Do you have allergies?
Select all that apply
Have you been formally tested for allergies?
Do you take anything to relieve allergy symptoms?
Select all that apply
Do you have nasal congestion that is not related to allergies?
If yes, please explain under "other"
Select all of the following that apply:
Have you ever seen an ENT for an evaluation?
If yes, at what age?
Has it been recommended to remove your tonsils and/or adenoids?
If yes, at what age and did you or your child have this procedure? (answer under "other")
Do you have a deviated septum?
Have you had braces?
If yes, at what age? (answer under "other")
Was expansion a part of your treatment?
Expansion typically includes an appliance that is worn, or placed, in the roof of one's mouth.
Have you had any relapse in your orthodontic treatment?
Please select all that apply.
Are you interested in realigning your teeth with Invisalign or traditional orthodontics?
Do you have a history of any of the following conditions?
Please select all of the following that apply:
Do you have pain in any of the following categories?
If yes, please describe the pain level (1-10) and frequency in "other" box.
Do you have tension in any of the following areas?
Please select all answers that apply:
Do you, or have you, used a night guard or splint?
Have you ever worked with any of the following professionals for body work?
Please select all of the following that apply:
Do you currently see a chiropractor?
How many hours of sleep do you get on average?
Do you wake up feeling well rested?
Do you often feel tired during the daytime?
Do you experience brain fog or forgetfulness?
Do you feel chronically fatigued or run down?
Do you experience insomnia?
How would you describe your sleep?
Select all of the following that apply:
Do you struggle to breathe through your nose at night?
Do you snore?
Have you ever had a sleep study?
If yes, please answer when this study was done under "other"
Do you currently have a CPAP or MAD?
If yes, how often do you use it? Please answer under "other"
Lightly seal your lips together, can you breathe through your nose like this for a full 2min?
Please select all of the following that apply:
Do you, or your child, have any oral aversions?
If yes, elaborate answer under "other"
Please select any of the following that apply:
Do you have a hyperactive gag reflex?
Please enter your email below
Enter email address below (this email will not be shared and is used only to save your survey results)
Date of birth:
(Optional)
Please set up a consultation to go over you, or your child's, results!
Set up a consultation through our website at omtduluth.com! We are located in Duluth, MN at Mount Royal Dental.
Thank you for completing this survey!
If you would like to set up a consultation with one of our myofunctional therapist, you can now book online! You can also reach us through out website or by calling 218-464-5222.
