Adult Case History

Magar Myofunctional and Speech Services

General Information

Date

Patient Name

Sex

Date of Birth

Age

Address

City

State

Zip

Home Phone

Cell Phone

Email Address

REFERRAL INFORMATION

Phone

Address

Concerns/Reasons for referral

Name of Primary Physician and address

Name of General Dentist and address

Name of Orthodontist and address

Other Medical Specialists (Neurologist or Ear-Nose-Throat Physician, etc.)

DEVELOPMENTAL HISTORY

Were there any problems during your mother’s pregnancy or difficulties with your delivery?

Were developmental milestones within normal limits?

Altered?

Were you bottle or breast fed?

How Long?

Were there initial feeding difficulties as an infant/toddler?

Have you ever

Sucked your thumb

Sucked your finger

Used a pacifier

When did the habit stop?

Do you have a history of other oral habits

Lip Licking

Lip Sucking

Cheek Biting/Sucking

Nail Biting

Please note if any of the above habits still exist

Other oral habits?

PRESENT EATING HABITS

Are you a fast or slow eater?

Slow Fast

Do you drink more than one glass of liquid with meals?

Yes No

Do you wash down food with liquids?

Yes No

Do you chew your food adequately?

Yes No

Do you choke easily?

Yes No

Gag easily?

Yes No

Do you belch often?

Yes No

Do you have digestive problems?

Yes No

History of reflux?

Yes No

Are you a noisy eater (smacking)?

Yes No

Messy eater?

Yes No

Is there audible gulping when swallowing?

Yes No

Do you chew with lips apart/mouth open?

Yes No

Do you avoid any foods due to difficulty chewing or due to texture sensitivities (please list)?

Do you have difficulty swallowing pills?

Yes No

DENTAL HISTORY

Were baby teeth normal?

Yes No

Were baby teeth lost at normal ages?

Yes No

History of any dental anomalies?

Do you have a history of cavities or periodontal disease?

Yes No

Other dental concerns?

Have permanent teeth been injured/chipped/extracted?

Yes No

List any prior orthodontic treatment you have received

OTHER RELATED QUESTIONS

Do you usually rest with lips together or open during the day ?

Together Open

When sitting idle do you tend to breathe through mouth or nose?

Mouth Nose

Do you have loud breathing?

Yes No

When sleeping do you sleep with lips open or closed?

Open Closed

Do you have a history of snoring?

Yes No

Dry mouth in the morning?

Yes No

Unrefreshing/Restless Sleep?

Yes No

Neck/Shoulder Pain?

Yes No

Wake up gasping for air

Yes No

Drool during then night?

Yes No

Do you wake up with a headache?

Yes No

Do you often feel sleepy or tired during the day?

Yes No

Do you take naps during the day?

Yes No

Do you fall asleep when involved in a quiet activity such as watching TV, reading , driving?

Yes No

Additional details with sleep pattern

MEDICAL HISTORY

Lingual Frenum Restriction (tongue tie)

Yes No

If Yes, Age diagnosed