Orofacial Myofunctional Therapy Health History Questionnaire

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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?

Bottle fed

Breast fed

Unsure

Other

Any difficulty with your latch during breastfeeding?

Please describe any difficulty with breastfeeding

Yes

Unsure

Other

Premature birth?

Yes

Unsure

Other

Long difficult Labor?

Yes

Unsure

Other

C-Section?

Yes

Unsure

Other

Tongue tied or lip tied as an infant?

If yes, were ties released or are they still present?

Yes

Unsure

Other

History of ear problems or infections?

Yes

Unsure

Other

Tubes placed in ears?

Yes

Unsure

Other

Current ear infection problems?

Yes

Unsure

Other

History of hyperactivity? Signs or symptoms of attention deficit disorder? Trouble paying attention?

Yes

Unsure

Other

Select all the following habits that apply:

Thumb sucking

Finger sucking

Nail biting

Prolonged pacifier use (6mo+)

Sucking on clothing/hair/blankets

None

Other

Have you been evaluated by a speech language pathologist?

Yes

Currently seeing an SLP

Other

If treated, what was the focus of speech therapy?

Do you believe there are any current speech concerns?

If so, what are they?

No, I do not believe there are any speech concerns.

"S" sound or lisp

"R" or "L" problems

General lack of clarity or mumbling

Voice projection

Unsure

Other

Select all of the following that apply:

Digestive problems

Abdominal bloating or cramping

Belching

Flatulence

Acid reflux/Heartburn/GERD

Laryngopharyngeal reflux (LPR)

Irritable bowel syndrome (IBS)

Leaky gut

Small Intestinal Bacterial Overgrowth (SIBO)

Crohn's disease

Colitis

None

Other

What is the frequency of your symptoms?

If you do not deal with digestive symptoms, or are unsure, select N/A.

Daily

Weekly

Monthy

N/A

Other

Do you have allergies?

Select all that apply

Yes

Seasonal

Dust

Pets/Dander

Other

Have you been formally tested for allergies?

Yes

Other

Do you take anything to relieve allergy symptoms?

Select all that apply

Yes

Allergy Medication

Home remedies (nasal spray, neti pot, etc)

Other

Do you have nasal congestion that is not related to allergies?

If yes, please explain under "other"

Yes

Other

Select all of the following that apply:

Headaches

Turbinate reduction

Nasal Polyps

Empty nose syndrome

Chin implant

Sinus infections

Pressure (neck and face region)

Septoplasty

Pain (please explain under "other")

None

Other

Have you ever seen an ENT for an evaluation?

If yes, at what age?

Yes

Other

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")

Yes

Other

Do you have a deviated septum?

Yes

Unsure

Other

Have you had braces?

If yes, at what age? (answer under "other")

Yes

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.

Yes

Unsure

Other

Have you had any relapse in your orthodontic treatment?

Please select all that apply.

Yes, I have had orthodontic relapse

No, I have not had orthodontic relapse

I do not wear retainers at night

I do wear retainers at night

N/A

Other

Are you interested in realigning your teeth with Invisalign or traditional orthodontics?

Yes

N/A

Other

Do you have a history of any of the following conditions?

Please select all of the following that apply:

Periodontal disease

Deep cleanings and/or deep pockets

Recession

Highly sensitive teeth

High rate of cavities (currently or as a kid)

None

Other

Do you have pain in any of the following categories?

If yes, please describe the pain level (1-10) and frequency in "other" box.

Neck pain

Shoulder pain

Migraines

Headaches

TMJ pain/TMD

Facial pain

None

Other

Do you have tension in any of the following areas?

Please select all answers that apply:

Neck tension

Shoulder tension

Migraines

Headaches

TMJ tension/TMD

Facial tension

Clenching of your teeth

Grinding of your teeth

None

Other

Do you, or have you, used a night guard or splint?

Yes

N/A

Other

Have you ever worked with any of the following professionals for body work?

Please select all of the following that apply:

Chiropractor

Physical Therapist

Occupational Therapist

Cranial Osteopath

Personal Trainer

Yoga Instructor

Massage Therapist

N/A

Other

Do you currently see a chiropractor?

Yes

Other

How many hours of sleep do you get on average?

Do you wake up feeling well rested?

Yes

Sometimes

Unsure

Other

Do you often feel tired during the daytime?

Yes

Sometimes

Unsure

Other

Do you experience brain fog or forgetfulness?

Yes

Sometimes

Unsure

Other

Do you feel chronically fatigued or run down?

Yes

Sometimes

Unsure

Other

Do you experience insomnia?

Yes

Sometimes

Unsure

Other

How would you describe your sleep?

Select all of the following that apply:

Interrupted

Restless

"Like a log"

Light sleeper

Deep sleep

Soaked in sweat

Wake up to use the restroom regularly

Other

Do you struggle to breathe through your nose at night?

Yes

Unsure

Other

Do you snore?

Yes

Sometimes

Unsure

Other

Have you ever had a sleep study?

If yes, please answer when this study was done under "other"

Yes

Other

Do you currently have a CPAP or MAD?

If yes, how often do you use it? Please answer under "other"

Yes

Other

Lightly seal your lips together, can you breathe through your nose like this for a full 2min?

Yes, that was easy!

Yes, but it was difficult

No, I could not breathe through my nose for 2min

I was unable to complete this exercise for myself of for my child at this time.

Other

Please select all of the following that apply:

Messy eater

Picky eater

Fast eater

Slow eater

Open mouth chewing

None

Other

Do you, or your child, have any oral aversions?

If yes, elaborate answer under "other"

Yes

Other

Please select any of the following that apply:

Air swallowing

Tongue thrust with swallowing

Difficulty swallowing pills (over age 12)

Saliva pooling during the day

Drool on pillow

History of choking

Frequent food or water "going down the wrong pipe" (aspiration)

Difficulty coordinating chewing and breathing

None

Other

Do you have a hyperactive gag reflex?

Yes

Sometimes

Unsure

Other

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)

Thank you for completing this survey!

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.