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 *

Referring provider: *

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 6-8 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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