Date *

MM

DD

YYYY

Name of Patient *

First Name

Last Name

Phone of Patient/Guardian

(###)

###

####

Please evaluate for the following OMDs: *

Check all that apply

Mouth Breathing

Tongue-Tie

Tongue Thrust

Low Tongue Posture

Sucking Habit

Nail Biting

Drooling

Lip competence

Short upper lip

Orthodontic retention/relapse

TMJ symptoms

Symptoms of sleep disordered breathing(SDB)

Speech concerns

Other