Name *

First Name

Last Name

Phone

(###)

###

####

NV Orofacial Myology Self Assessment *

Mark any symptom you have or had previously. Please be advised this is a self-assessment and not a medical diagnosis.

Frequent Sore Throat

Speech Issues

Thumb Sucking

Nail Biting

Chapped Lips

History of Ear Tubes

Chronic Ear Infections

Chronic Head/Neck/Shoulder Pain

Mouth Breathing

Tongue Rests Low/Protrudes

Receded (sunk in) Chin

Snoring

Frequent Congestion

Daytime Sleepiness

Restless Sleep

ADD/ADHD

Sleep Walking

Sleep Apnea

Family History of Obstructive Sleep Apnea

Clenching/Grinding Teeth

TMD (Jaw Pain)

Insomnia

Acid Reflux

Picky Eating

Difficulty Swallowing Certain Foods

Difficulty Swallowing Pills

Strong Gag Reflux

Open Mouth Chewing

Bed Wetting Beyond 6 yrs

Asthma

Crowded Teeth, Bad Bite

Anxiety/Chronic Stress