Full Name

Email *

Phone *

Subject

Airway/Breathing Evaluation

Select all that apply

No - Can you hold a popsicle stick or folded sticky note between your lips and breathe through the nose for 3 minutes?

Tonsils and/or adenoids removed in past

Patient Breathes through their mouth during the day more than 50%

Patient Breathes through their mouth or snores at night

Asthma, allergies, chronic congestion, sinus problems/infections

Deviated septum/nasal/airway surgery

Tonsils/adenoids enlarged and visible

Can you see the back of your throat when you open?

A small amount

Does your tongue have scalloping on it?

Tongue scalloping is the wavy or rippled indentation along the edges of the tongue

Dental Evaluation

Select all that apply

Anterior or lateral open bite and/or crossbite

Large spaces and/or tipping of teeth

Relapse of previous orthodontic treatment

Expansion required during orthodontic treatment and/or high, narrow palate

Tongue crib or tongue guard required during orthodontic treatment

History of orthodontic or orthognathic surgery (or recommended)

Premolars extracted

Mouth Resting Posture

Mouth is open often, but not greater than 50%

Mouth is open greater than 50%

Unsure of where my lips rest most of the time

Mouth breathing any time during the day or night

Tongue Posture

Tongue is positioned low, in bottom of mouth, not against palate

Tongue tip is against upper or lower teeth

Tongue tip is between upper and lower teeth

Back of the tongue is floating or between the teeth

Unsure of where tongue rests in the mouth

Digestive Concerns

Select all that apply

Digestive issues more than once per week

Acid reflux symptoms

Bloating, burping, hiccupping or gas

History or current issues with constipation or diarrhea

SIBO, IBS, other digestive issues

Alterations to diet - eliminating dairy, gluten

Swallowing

Select all that apply

Tongue thrust swallowing pattern (tongue touches teeth when you swallow)

Trouble with drooling/saliva pooling

Difficulty breathing while eating, open mouth chewing, or use of liquids to swallow food

Picky Eater or Messy Eater

Water goes down the wrong pipe sometimes or choking on food

Difficulty swallowing pills

Hyperactive gag reflex

Head and Neck Concerns and Posture

Select all that apply

Headache more than once per week

Jaw/facial pain more than once per week

Neck/shoulder pain tension

Grinding/clenching at night, night guard worn or recommended

Forward head/neck posture

Rolled shoulders

Have worked with massage, chiropractor, craniosacral therapist, other body work professional

Facial Muscle Movement/Structure

Select all that apply

Can you whistle? : No

Can you wink? : No , one side only

Can you click your tongue? : No

Make taco tongue?: No

Big, Cheesy Smile with pain or tension? : No

Lift Eyebrows? : Yes, but pain

Does Your Neck Flex when you Smile or feel tension in the neck? : Yes

Restricted Lingual Frenum (Tongue-Tie)

Select all that apply

Lingual frenum was released as a baby

No - Can you suction your tongue to the roof of your mouth and hold it for 1 minute?

No - Can you suction your tongue to the roof of your mouth and open more than 30%?

Yes - Can you suction your tongue to the roof of your mouth and open more than 30%?

Do you have a heart shape on the end of your tongue?

Does the frenum or string on your tongue attach to your lower front teeth? (looks like the Eiffel Tower)

Does your jaw move side to side or drag on your teeth when you move your tongue from side to side?

Do you have pain when you reach the tip of your tongue upwards behind your top front teeth?

No - Does your tongue lift more than 50% to reach your top front teeth with mouth wide open?

Next Steps and Scoring

Total Score

We recommend Myofunctional Therapy treatment to anyone who checks 25 or greater boxes during this self assessment. If you are ready to take the next steps in your airway journey we have options for you!

Early Childhood/Birth/Feeding/Oral Habits

Speech History

Airway/Breathing Evaluation

Can you see the back of your throat when you open?

Dental Evaluation

Mouth Resting Posture

Tongue Posture

Digestive Concerns

Swallowing

Head and Neck Concerns and Posture

Facial Muscle Movement/Structure

Sleep

Restricted Lingual Frenum (Tongue-Tie)

Next Steps and Scoring