Medical History Form Although Myofunctional Therapists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the therapy you will receive. Thank you for answering the following questions. Name *BirthdateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you under a physician’s care now?Select Yes or NoYesNo If yes please describeAllergies? Please check all that applyAspirinPenicillinCodeineAcrylicMetalLatexOtherFood Allergies? Please list belowEnvironmental Allergies? Please list belowHave You Had Allergy Testing?Select Yes or NoYesNoIf Yes With Whom?Have You Had Allergy Shots?Select Yes or NoYesNoAre you taking any medication, vitamins or herbs?Select Yes or NoYesNoIf you answered yes to the above please list medication and dosageHave you ever had a serious head or neck injury? Select Yes or NoYesNo If yes please describeMajor Events / Past Medical History: Please list yearOngoing Medical ProblemsPreventive CareSocial HistorySmokingAlcoholControlled substancesActivities involved withMusical Instruments played Nutrition History: Please list specific foodsHigh sweet intake?Select Yes or NoYesNoFinicky eater?Select Yes or NoYesNoLimited Fruits/vegetables? Developmental HistoryBirthComplicationsInfant feeding method/how longType of nipple used on bottle/pacifierHow long for pacifier/thumb sucking Use of sippy cup/how long Crawl/Walk/Talk MilestonesPrior speech therapySelect Yes Or NoYesNoIf yes, with whom?How LongPlease describePain SymptomsJaw clenching or grindingSelect OptionDayNightDo you wear a mouth guard?Select Yes or NoYesNoPast treatment sought for pain?Select Yes or NoYesNoOrthodontic HistoryOrthodontist nameCurrent applianceUpper/lower BracesAppliancesRetainersPositionersOrthoticRelapseYears Rx.ConcernsThumb/Finger HabitTongue ThrustSpeech concernTMJ concernRelapseIn BracesSnoringSleep apneaAdditonal CommentsPhoneSubmit
