Patient Info:

Patient First Name*

Patient Last Name*

Patient DOB*

Month

Day

Year

Patient Phone*

Patient Email

Evaluation Area(s):*

Tongue thrust swallowing pattern

Tongue tie/restricted lingual frenum

Open Mouth rest posture

Pre/Post frenectomy care

Mouth breathing

Thumb/finger sucking habit

Concerns Noted:

TMJ disorder/pain/discomfort

Sleep apnea/sleep disordered breathing/snoring

Speech Problems

Headaches/clenching/grinding

Adenoid/tonsil hypertrophy

Other

Referring Office

Referring Doctor/Practice:*

Referring Email:*

Referring Phone:*

Doctor Notes:

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