Contact Us | Personalized Care at My Functional Smile

My Functional Smile

Myofunctional Therapy

Request An Appointment

My Functional Smile

Myofunctional Therapy

Assessment

Symptom Assessment Form

Please fill out this questionnaire to provide a basis for our exam and allow us to focus on the specific symptoms that you or your child experience.

Please answer these questions below to the best of your knowledge.

Name *

Email *

Age *

Do you snore or breathe through your mouth at night? *

Yes

No

Maybe

Have you been diagnosed with sleep apnea? *

Yes

No

Do you struggle with seasonal allergies? *

Yes

No

Maybe

Do you have any food sensitivies? *

Yes

No

Maybe

Do you notice that you occasionally have your mouth open at rest or that you breathe through your mouth during the day? *

Yes

No

Maybe

Do you feel chronically tired or fatigued even when you get enough sleep? *

Yes

No

Maybe

Has anyone ever told you that you may be tongue-tied? *

Yes

No

Maybe

Do you regularly experience any issues with digestion? (stomach pain, gas, bloating, acid reflux, etc.) *

Yes

No

Maybe

Have you had any nasal or airway surgeries or do you have a deviated septum? *

Yes

No

Do you have any jaw pain, facial pain, or headaches on a regular basis? *

Yes

No

Do you clench or grind your teeth or wear a night guard at night? *

Yes

No

Maybe

Have you ever been evaluated by a myofunctional therapist? If so, tell us what they recommended. *

Are you able to commit to practicing exercises for at least 5 minutes every day? *

Yes

No

Are you able to meet with your therapist for 30-45 minutes every 2-3 weeks for a 6-8 month period? *

Yes

No

Is there anything else you would like us to know? *

Generally, if any of these questions can be answered "yes", it is likely that you have some myofunctional concerns. If you answered "yes" to multiple questions, myofunctional therapy will be recommended. We look forward to seeing you soon. Thank you!