Client Name
Email
Evaluation Date
Age
Date Of Birth
Phone
School, Grade
Parents
Siblings
Referral Source
Orthodontist
Dentist
Physician
Summary
Notes
Noxious Habits — Type
Noxious Habits — Status
Noxious Habits — Duration
Breathing
Allergies
Allergies — Explain
Patent Nares — Left
Patent Nares — Right
Nasal Bridge
Mentalalis
Masseters
Weaker Side
TMJ Symptoms
Describe
Mandible — Stability
Horizontal
Lateral
Vertical
Shift Upon
Hard Palate
Tonsils
Gag
Velum
Dentition
Dentition Notes
Lips
Posture
Function:
Lip/Mandibular Differentiation — Spread
Lip/Mandibular Differentiation — Round
Lip Meter — Up
Lip Meter — Mid
Lip Meter — Down
Max. Resistive Strength: (Avg = 3.0-5.0 RU)
Maintain “Kissing” Suction
Tongue — Position In Repose
Maintain Rest Position for 5 seconds
Elevate
Frenum
QTT — MO (max) mm
QTT — MOWS mm
QTT — MO (tts) mm
Narrow at Will
Click / Weak / Suction
Palatal Accommodation Overflow
Swallow
Eating
Chewing
Bolus Collection
Drinking
Voice, fluency, other comments
/s/, /z/
/ch/, /sh/, /dj/, /zh/
/t/, /d/, /n/
/l/
CLINICAL IMPRESSIONS
PROGNOSIS AND ESTIMATED DURATION OF TREATMENT
RECOMMENDATIONS
Kerri Salvatore, MS, CCC/SLPSpeech/Language PathologistOrofacial Myologist
