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Birthday
Year
Month
Day

Section 1; Breathing & Sleep

Do you breathe out of your mouth or nose during the day?
Nose
Mouth
How do you breathe during the night?
Nose
Mouth
Unsure
Do you snore or take pauses during your sleep?
Yes
No
Unsure
Do you wake up frequently during sleep?
Yes
No
Do you often feel tired, even after a full night's sleep?
Yes
No
Do you often need a nap or find yourself falling asleep in odd places?
Yes
No
Have you been told you grind your teeth or clench your jaw?
Yes
No
Unsure
Yes, I wear a night guard
Have you ever had a sleep study done?
Yes
No

Section 2; Oral Habits & Function

Do you have difficulty keeping your lips together at rest? (when reading, listening, watching or scrolling?)
Yes
No
Unsure
Check right now! Does your tongue rest between your lower teeth, middle of the mouth or up on the roof of the mouth?
Low resting tongue
Middle
High resting tongue
Unsure
Watch yourself swallow water or saliva, do you see your lips separate or your tongue poke through the teeth / lips?
Yes
No
Unsure
Do you struggle with swallowing pills, food or chewing food?
Yes
No

Section 3; Speech & Facial Development

Do you have difficulties with speech such as a lisp or poor articulation?
Yes
No
Unsure
Do you notice any of the following?

Section 4; Posture, Health & Behaviour

Do you regularly experience neck, shoulder or jaw tension?
Yes
No
Are you prone to allergies, chronic congestion, or sinus issues?
Yes
No
Other
Do you have a diagnosis of ADD or ADHD?
Yes
No
Other
Do you experience frequent headaches or jaw pain?
Yes
No
Yes, but not frequent
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