Has your child ever had a thumb or finger sucking habit?

Yes

No

Has your child ever had or still does have allergies or food sensitivities?

Yes

No

Have you notice that your child occasionally has his/her mouth open at rest?

Yes

No

Has your child ever had troubles with speech, or been in a speech therapy program?

Yes

No

When swallowing, do you see your child’s tongue come forward (out of the mouth)?

Yes

No

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

Yes

No

Has your child experienced any issues with digestion? (Stomach aches, burping, gas, acid reflux, etc.) or has a hyper-active gag reflex?

Yes

No

Has your child experienced any breathing issues or difficulties (Chronic congestion, asthma, etc.) & tends to breathe through his/her mouth more than their nose?

Yes

No

Name *

First Name

Last Name

Phone (not required)

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