Health History

Answer to the best of your ability; we will elaborate on these questions at your initial appointment.

Patent First Name *

Patient Last Name *

Date of birth *

Address

Street Address

City

State

Country

Postal Code

What concerns do you have that brought you to inquire about myofunctional therapy? *

May we thank anyone for referring you to our practice?

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Health History

Do you have any conditions, diagnoses, suspected ailments, etc?

List any medications and supplements you are taking:

Who is your doctor?

Other physicians or professionals actively involved in your health care:

List any allergies:

Do you regularly participate in any therapies not listed above (PT, chiro, massage, etc.)?

Have you experienced any significant injuries or surgeries?

Any other health history notes?

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Sleep

Have you ever had a sleep study?

No

Not yet, but planning to, or it has been recommended

Yes

What position do you usually sleep in?

Do you breathe through your nose or mouth at night?

Nose

Mouth

Mixed

Do you wake feeling well rested?

Yes

No

Sometimes

Do you use any sleep aids or devices?

Yes

No

I used to or it has been recommended

Any other sleep notes?

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Breathing

Any other breathing notes?

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Dental Health

Who is your dentist? Include any dental professionals, such as your orthodontist, periodontist, etc.

How would you describe your general dental health and history?

Have you had orthodontia?

Yes, currently

Yes, in the past

No

No, but it has been recommended

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Oral Habits + Function

If known, in what position is your tongue at rest?

Any other notes about oral habits and function? If an oral habit was or is present, please describe:

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Head and Neck

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Other

How would you describe your posture?

Please include any details for items checked above:

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Birth + Early Childhood

Any other notes about infancy/childhood?

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Family History

Please note any family history involving any of the above concerns; including history of oral ties, orthodontic intervention and sleep habits:

Is there anything else you would like us to know?