Adult Intake Form

Name *

First

Last

Phone Number *

Address *

Email *

Do you usually breathe through your mouth?

Yes
No

Do you snore while sleeping?

Yes
No
Don't Know

Do you stop or pause your breathing while sleeping?

Yes
No
Don't Know

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

Yes
No

Do you use sleep medication?

Yes
No

Do you have any facial pain?

Yes
No

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

Yes
No

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

Yes
No

Do your gums bleed?

Yes
No

Is your pillow wet in the morning?

Yes
No

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

Yes
No

Do you easily catch colds?

Yes
No

Do you have allergies?

Yes
No

Do you have a history of the following:

Thumb sucking
Finger sucking
Tongue sucking
Nail bitting

Do you have difficulty pronouncing sounds?

Yes
No

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?

Website

Patient Forms

Adult Intake Form
Child Intake Form

Helpful Resources

International Association of Orofacial Myology (IAOM)
American Speech and Hearing Association (ASHA)
American Dental Association
American Association of Orthodontics
American Academy of Otolaryngology
Association of Women Dentists

This website has been awarded
the official IAOM Seal of Approval

Proud participate of the
Metro Dentist Network

Patient Forms
- Adult Intake Form
- Child Intake Form
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