Myofunctional Medical History

FORM COMPLETED BY:

DATE COMPLETED:

PATIENT’S FULL NAME:

DATE OF BIRTH:

SEX:

MALE FEMALE

GENDER:

GENDER IDENTITY:

HOME ADDRESS (street, city, state, and zipcode):

MAIN PHONE NUMBER:

PREFERRED METHOD OF CONTACT:

HOME CELL EMAIL

Email Address

DIAGNOSIS:

ALLERGIES/PRECAUTIONS:

PRIMARY LANGUAGE SPOKEN AT HOME:

Insurance Carrier

Insurance ID Number:

Insurance Group Number:

Insurance Policyholder Name:

Insurance Policyholder Date of Birth:

Insurance Policyholder Relationship to Patient:

Referral Source:

PRIMARY DOCTOR AND NAME OF CLINIC:

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

NAME:

PHONE NUMBER:

PHONE NUMBER 2:

RELATIONSHIP TO CLIENT:

ADDRESS:

DENTAL HISTORY INFORMATION:

DENTIST NAME:

NAME AND ADDRESS OF DENTAL PRACTICE:

PHONE NUMBER / FAX NUMBER:

NAME OF ORTHODONTIST:

NAME AND ADDRESS OF ORTHODONTIST PRACTICE:

PHONE NUMBER / FAX NUMBER:

I. TEETH

Are you presently wearing braces?

Yes No

If yes, for how long and when will they come off?

If no, have you worn braces before?

Yes No

If Yes, when and for how long?

If no, are you going to be getting braces?

Yes No

Are you presently wearing, or have you worn, any dental appliance? (write in dates)

List name of appliance and how long it was worn

When do you expect the appliance to be removed?

Other

If you have braces, has your orthodontist ever expressed difficulty in getting your teeth to move or stay properly?

Yes No

Please explain:

Have you been diagnosed or suspect a tongue-tie?

II. EATING AND DRINKING

Did you ever have difficulty nursing, taking a bottle, or eating when an infant?

Yes No

Please explain.

III. RESPIRATION

Please explain allergies/asthma and any medications used.

Tonsils and / or adenoids removed? Please list date.

Have you consulted with ENT and what was outcome?

Comments:

IV. THUMB/FINGER SUCKING

I presently suck my thumb or fingers:

I want to stop I don’t really want to stop

I have sucked my thumb or fingers in the past; Here is how I stopped:

Comments:

V. SPEECH

Speech problems

No, I do not have a speech problem

I have had a speech problem in the past (explain below)

Yes, I currently have a speech problem (explain below)

I have had speech therapy (explain below)

I have not had speech therapy (explain below)

Please explain any speech problems and speech therapy here.

Comments:

VI. JAW OR FACIAL PAIN

What providers have you seen for the pain?

What aggravates your pain?

What makes it feel better?

Insurance Card Front and Back

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