Symptom assessment Form

Please ﬁll out this questionnaire to provide a basis for our consultation and allow us to focus on the speciﬁc symptoms that you experience. Please answer these questions to the best of your knowledge.

First Name

Last Name

Phone *

Age

Email *

Do you snore or breathe through your mouth at night?

Yes

Maybe

Have you been diagnosed with sleep apnea?

Yes

Do you notice that you occasionally have your mouth open at rest or that you breathe through your mouth during the day?

Yes

Do you feel chronically tired or fatigued even when you get enough sleep?

Yes

Has anyone ever told you that you may be tongue-tied?

Yes

Do you have any jaw pain, facial pain, or headaches on a regular basis?

Yes

Sometimes

Do you clench or grind your teeth or wear a night guard?

Yes

I am not sure

Have you ever undergone jaw surgery?

Yes

was recommended one

Are you able to commit to practicing exercises for at least 30 minutes every day? *

Yes

Are you able to meet with your therapist for 45-60 minutes every 2-3 weeks for a 6-10 month period?

Yes

Are you genuinely motivated and committed to changing your health and live Pain Free life?

Yes

The cost of our program is a set fee of $2500 Are you able to pay for the program without insurance coverage? HSA/FSA (Flex spending accepted)

Yes

I'd like to know the financing options available

Is there something going on in your life right now that would prevent you from doing therapy?

Is there anything else you'd like us to know? *

Generally, if any of these questions can be answered "yes", it is likely you have some myofunctional concerns. If you answered "yes", to multiple questions, myofunctional

therapy will be recommended

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