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HOME OBSERVATION FORM
PERSONAL INFORMATION
First Name
Last Name
Email
Cell phone:
Home phone
MEDICAL INFORMATION
Blood Pressure:
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Diabetes:
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Heart Disease:
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Stroke:
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Digestive Issues?
PTSD?
Neurological Disorders:
Chronic Cough?
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Respiratory Issues?
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Acid Reflux?
Asthma?
Allergies?
Do you have (check all that applies)
Behavior problems
Depression
Memory loss
ADHD
ADD
On the Spectrum
Concentration problems
Anxiety
Tics
Headaches or migraines
Muscle tension in the head face neck or chest
Tonsils and or Adenoids removed
Injury to head/face/neck at any age
Eustachian tube placement
Earaches
Problems breathing through the nose
MEALTIME
Pack food in the cheeks?
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Stick tongue out to take the food in?
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Loud drinking?
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Swallow soon after putting food in the mouth?
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Food texture sensitivity?
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Chewing with mouth open?
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Loud eater?
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Eat too fast?
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Swallow air while swallowing food?
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Engagement of the lips, cheeks or chin muscles during the actual swallow (look in a mirror)
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DO YOU OPEN YOUR MOUTH
While watching TV?
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Doing homework?
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While playing?
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While on the computer?
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Reading?
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While having conversation?
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Sleeping?
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SLEEPING
Trouble falling asleep?
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Restless (tossing and turning)?
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Loud snoring?
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Craning neck back?
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Awaken unrefreshed?
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Clenching?
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Bed wetting?
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Trouble staying asleep?
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Loud breathing?
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Cessation of breath?
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Awaken frequently?
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Daytime fatigue?
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Grinding?
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Awaken to urinate?
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Night terrors/Sleepwalking?
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Have you had a Sleep study?
FUNCTIONAL QUESTIONS
(Do the best you can with these)
Breast fed?
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Lactation issues?
Bottle fed?
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Pacifier use?
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Biting? (check all that applies)
No
Nails
Inside cheek
Lip
Shirt
Pen/pencil
Thumb sucking?
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Sippy cup usage?
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Speech therapy?
Feeding therapy?
OTHERS
Medications and for what:
All history of orthodontics
Alcohol consumption?
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What bodywork (therapies) have you done or do you do?
Your main reason for seeking Myo Therapy?
Any disorders not mentioned?
Comments:
ONE LAST QUESTION!
Who Referred You or How Did You Find Us?
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