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My Functional Smile

Myofunctional Therapy

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My Functional Smile

Myofunctional Therapy

Assessment

Symptom Assessment Form

Please fill out this self assessment form to find out if you are a candidate for myofunctional therapy.

Answer these questions below to the best of your knowledge.

Full Name *

Email *

Age *

Do you snore or breathe through your mouth at night? *

Yes

No

Maybe

Have you been diagnosed with sleep apnea? *

Yes

No

Do you struggle with seasonal allergies? *

Yes

No

Maybe

Do you have any food sensitivies? *

Yes

No

Maybe

Do you notice that you occasionally have your mouth open at rest or that you breathe through your mouth during the day? *

Yes

No

Maybe

Do you feel chronically tired or fatigued even when you get enough sleep? *

Yes

No

Maybe

Has anyone ever told you that you may be tongue-tied? *

Yes

No

Maybe

Do you regularly experience any issues with digestion? (stomach pain, gas, bloating, acid reflux, etc.) *

Yes

No

Maybe

Have you had any nasal or airway surgeries or do you have a deviated septum? *

Yes

No

Do you have any jaw pain, facial pain, or headaches on a regular basis? *

Yes

No

Do you clench or grind your teeth or wear a night guard at night? *

Yes

No

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Links

My Functional Smile - Myofunctional Therapy

Privacy Policy I Terms & Condition