Myofunctional Medical History: 8yo and Up

Please correct the errors described below.

PARENT / PRIMARY CAREGIVER INFORMATION:

EMERGENCY CONTACT INFORMATION (other than parent/primary caregiver):

CURRENT SCHOOL INFORMATION:

I. TEETH

Are you presently wearing, or have you worn, any of the following? (write in dates)

II. EATING AND DRINKING

III. RESPIRATION

IV. THUMB/FINGER SUCKING

V. SPEECH

VI. JAW OR FACIAL PAIN

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