patient evaluation Name *Date MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please check all that apply to your conditionUsual position of the lips and teeth during the daytimeOpen WideOpen SlightlyClosedLips closed, but jaw position lowLips closed, but strong contraction of the chin and lip muscleTeeth positioned over lower lipDaytime poolingUsual position of the tongue, lips and teeth during sleepLips slightly partedLips apart, tongue showingMouth breathingLips ClosedNight time droolingSnoringSleep apneaUsual position of the tongue during the daytimeProtruding between both teeth and lipsProtruding slightly between teethLow positioned, pressing against lower teethOther If other selected please explainDaytime body postureThird ChoicePoorAverageGoodFace leaningChin leaningRight/left head carriageSlumped shouldersSlouchesSits at anglesSpinal curvature historySleeping postureBackLeft sideRight sideStomach (facing left/right side)Restless SleeperQuiet sleeperNumber of pillowsSnores/sleep apnea historySpecial loveyOral HabitsThumb or finger suckingTongue suckingLip bitingLip licking (chapped lips)Pencil bitingFinger nail bitingObject bitingMouth breathingTooth grinding (bruxing)DroolingFacial, tooth, head or neck painFacial mannerismsOther HabitsHair PullingEyelash/eyebrow pullingNose pickingLeaning habitsOtherIf other selected please explainDrinking patternsMustache after drinkingDrinks oftenGulpsMeets glass with tonguePours in liquidsBalloons cheeks with liquid before swallowingChewing PatternsChews with lips openChews with excessive lip and chin movementChews with lips closedNoisy chewing, smackingForward-thrusting of tongue during chewingLarge bitesReaching out with the tongue to meet the food or liquidTeeth touch utensil, cup or glassExcessive crumbs around mouth and frequent lip lickingFast/ moderate/slow chewingMessageSubmit
