Patient Name *

First Name

Last Name

Please Evaluate the Following:

Check all that apply.

Tongue thrust

Mouth breathing

Tongue tie

Low tongue posture

Lip tie

Lip incompetence

Short upper lip

Orthodontic retention / relapse

Drooling

Sucking habits (e.g., thumb or lip)

Oral habits (e.g., fingernail biting)

Symptoms of sleep disordered breathing

Speech clarity

Other