Pediatric Myofunctional Intake Form

Child's Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Age

Sex Assigned at Birth / Gender Identity

Parent/Guardian Full Name

First NameMiddle NameLast Name

Relationship to Child

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Main reason for the visit

Symptoms or concerns prompting the appointment

When did the concern start?

Date

How has the concern changed over time?

Prior evaluations or diagnoses related to this concern

Previous therapy or treatment attempts

Which oral habits are currently present?

Thumb or finger sucking frequency

Pacifier use status

Bottle use status

Tongue thrust status

Nail biting frequency

Teeth grinding or clenching

Other functional patterns or oral habits noted

Breathing pattern during the day

Breathing pattern during sleep

Snoring

Sleep concerns observed

Observed pauses in breathing during sleep

Daytime fatigue or sleepiness

Trouble waking in the morning

ENT or allergy history relevant to breathing or sleep

Feeding concerns

Swallowing or chewing difficulties

History of choking or gagging with food or liquids

Food selectivity or texture aversion

Speech or articulation concerns

Orthodontic and dental history

History of tongue tie or lip tie

Medications, allergies, and relevant medical conditions

Prior therapies or interventions

Surgeries or significant medical procedures

Pediatric Myofunctional Intake Form

Patient and Guardian Information

Primary Concerns and Intake History

Oral Habits and Functional Patterns

Breathing, Sleep, and Airway Concerns

Feeding, Swallowing, Speech, and Medical Background