Self-Assessment Questionnaire

Assess Your Orofacial Health and Sleep Quality

Instructions: Please answer the following questions with a simple "Yes" or "No" to assess your orofacial health and sleep quality. Be honest in your responses to gain a better understanding of your current situation. Remember, this questionnaire is for informational purposes only and does not replace professional medical advice.

Self Assessment

Do you snore or breathe through your mouth during sleep?

Yes
No

Do you predominantly breathe through your mouth during the day?

Yes
No

Do you wake up feeling tired and not well-rested?

Yes
No

Have you ever been diagnosed with or suspect you have Sleep apnea or any form of sleep disordered breathing?

Yes
No

Have you ever been diagnosed with or suspect you have: TMJ disorder or head, neck ,or jaw pain, chronic headaches?

Yes
No

Have you ever been diagnosed with or suspect you have breathing issues such as chronic congestion, asthma, seasonal allergies?

Yes
No

Have you ever been diagnosed with or suspect you have Tonsil or adenoid enlargement or have them removed?

Yes
No

Do you have any habits or behaviors that may affect your oral and orofacial health?

Yes
No

(Thumb or finger sucking, nail biting, lip biting or chewing, tongue thrusting or improper swallowing pattern, Clenching or grinding teeth during the day)

Are you currently undergoing or have you undergone orthodontic treatment in the past?

Yes
No

Have you ever had a tongue tie or tongue mobility issues diagnosed or treated?

Yes
No

Are you interested in learning more about orofacial myofunctional therapy and its potential benefits for your sleep quality and overall oral health?

Yes
No

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The Journey Toward A Healthier Life starts with a Single Step

Starting Orofacial Myofunctional Therapy now can create a cascade of benefits that last a lifetime, enhancing overall quality of life. Contact us today to determine if Orofacial Myofuntional Therapy might be right for you.

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Contact Info

Our new office is located in the Matthews suburb of Charlotte.

3013 Senna Dr
Suite B
Matthews, NC 28105

tricia@charlottemyo.com

(704) 891-3262

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