Have you ever had a thumb or finger sucking habit?

Yes

No

Do you notice that occasionally your mouth is open at rest?

Yes

No

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

Yes

No

Have you experienced any issues with digestion (Stomach aches, burping, gas, acid reflux, etc) or difficulty swallowing pills?

Yes

No

Have you experienced any breathing issues or difficulties & breathe through your mouth more often than your nose. (Chronic congestion, asthma, seasonal allergies etc.)

Yes

No

Do you notice when swallowing your tongue thrusts forward?

Yes

No

Name *

First Name

Last Name

Phone (not required)

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