Adult Intake Form

Name *

First

Last

Phone Number *

Address *

Email *

Do you usually breathe through your mouth?

Do you snore while sleeping?

Do you stop or pause your breathing while sleeping?

Do you easily get tired or fall asleep during the day?

Do you use sleep medication?

Do you have any facial pain?

Do you have difficulty opening or closing your mouth or while chewing?

Do you clench or grind your teeth during the day or night?

Do your gums bleed?

Is your pillow wet in the morning?

Do you keep your mouth open while watching TV or using the computer?

Do you easily catch colds?

Do you have allergies?

Do you have a history of the following:

Do you have difficulty pronouncing sounds?

What do you hope to achieve from this evaluation?

Describe the problem you’re experiencing

What do you think caused the problem?

What have you tried to fix the problem?

Comment

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