Putting the pieces together Intake Form Date MM DD YYYY Referred By Patient's Full Name * First Name Last Name Age * Parent/Guardian First Name Last Name Relation to Patient Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Reason for Referral Orofacial Myology / Evaluation / Case history / Complete exam Mouth breather Digit habit control (thumb/fingers) Tongue thrust Lisp Open lip or incorrect lip resting posture Speech difficulties Prolonged soother use Low or forward resting tongue posture Swallowing difficulties or incorrect swallowing patterns Tongue-tied or was previously Imprecise articulation of speech sounds Airway concerns Thank you for submitting your intake form. I will call you to book your appointment.
