Orofacial Myofunctional Questionnaire

Today's Date:*

Child's First Name*

First

Child's Last Name:*

Last

Date of Birth:*

Phone*

Email*

Medical History

How many weeks gestation was your child born at?

Please list any relevant birth history:

Including: loss of oxygen, fetal distress, NICU stay, and any other complications during pregnancy, delivery, or the newborn phase.

Dentist Name & Phone Number

Orthodontist Name & Phone Number

ENT Name & Phone Number

Date & results of most recent hearing screening:

My child has had recurring ear infections

How many ear infections has your child had in the last 12 months?

Please select all that apply:

If any boxes are checked above, please elaborate, including age diagnosed, severity and other pertinent information:

Feeding History

Please do not skip this section, even if you do not have feeding concerns.

Breast Feeding History

Select all that apply. My child:

Latched immediately following birth
Had trouble latching at birth but eventually figured it out
Third ChoiceHad trouble latching at birth and breastfeeding was unsuccessful
Has/had a shallow latch
Uses/used a nipple shield to successfully breastfeed
Uses/used a supplemental nursing system (SNS)
Uses/used a finger feeder
Uses/used a syringe for feeding

Bottle Feeding:

Please list any and all bottles and/or feeding systems attempted to date:

Please add any additional information that you feel is important to share regarding breast or bottle feeding (e.g., if you worked with an IBCLC or other feeding therapists, if you needed to triple feed your baby, etc):

Age my child ate cut up table/finger foods (ex: peas, rice, dices peaches):

Age my child drank from a straw cup:

Age my child drank from an open cup:

Age my child used a spoon and fork independently:

Age my child weaned from breastfeeding:

Age my child weaned from bottle feeding:

Age my child weaned from pacifier use:

Age my child weaned from sappy cup use:

Please check all apply to your child:

Where does your child sit during mealtimes/when eating?

*Other location:

My child ate their first birthday cake.

Please explain any difficulties or concerns regarding feeding:

Social History

What opportunities does your child have to play with kids their age?

Does your child prefer to play alone or with others?

Nighttime/Sleep Breathing

Please check all that apply to your child:

How many hours per night does your child sleep?

Orofacial Myofunctional Questionnaire

Fill Out the Orofacial Myofunctional Questionnaire

Myofunctional Questionnaire

Medical History

Feeding History

Social History

Nighttime/Sleep Breathing