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Please check all that apply to your condition
Usual position of the lips and teeth during the daytime
Open Wide
Open Slightly
Closed
Lips closed, but jaw position low
Lips closed, but strong contraction of the chin and lip muscle
Teeth positioned over lower lip
Daytime pooling
Usual position of the tongue, lips and teeth during sleep
Lips slightly parted
Lips apart, tongue showing
Mouth breathing
Lips Closed
Night time drooling
Snoring
Sleep apnea
Usual position of the tongue during the daytime
Protruding between both teeth and lips
Protruding slightly between teeth
Low positioned, pressing against lower teeth
Other
If other selected please explain
Daytime body posture
Third Choice
Poor
Average
Good
Face leaning
Chin leaning
Right/left head carriage
Slumped shoulders
Slouches
Sits at angles
Spinal curvature history
Sleeping posture
Back
Left side
Right side
Stomach (facing left/right side)
Restless Sleeper
Quiet sleeper
Number of pillows
Snores/sleep apnea history
Special lovey
Oral Habits
Thumb or finger sucking
Tongue sucking
Lip biting
Lip licking (chapped lips)
Pencil biting
Finger nail biting
Object biting
Mouth breathing
Tooth grinding (bruxing)
Drooling
Facial, tooth, head or neck pain
Facial mannerisms
Other Habits
Hair Pulling
Eyelash/eyebrow pulling
Nose picking
Leaning habits
Other
If other selected please explain
Drinking patterns
Mustache after drinking
Drinks often
Gulps
Meets glass with tongue
Pours in liquids
Balloons cheeks with liquid before swallowing
Chewing Patterns
Chews with lips open
Chews with excessive lip and chin movement
Chews with lips closed
Noisy chewing, smacking
Forward-thrusting of tongue during chewing
Large bites
Reaching out with the tongue to meet the food or liquid
Teeth touch utensil, cup or glass
Excessive crumbs around mouth and frequent lip licking
Fast/ moderate/slow chewing
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Bimaxillary Case Study
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