Patient Name

Parent Name

DOB

Phone

Email

Date

Referred by

Please evaluate the following: Please evaluate the following: Tongue thrust swallowing pattern Open mouth rest posture Mouth breathing Tongue-tie/restricted lingual frenum Post-frenectomy care Thumb/finger sucking habit

Other concerns noted: Other concerns noted: TMJ disorder/pain/discomfort Speech problems Adenoid/Tonsil hypertrophy Sleep apnea/sleep disordered breathing / snoring Headaches/clenching/grinding Thumb/finger sucking habit

other