Adult Assessment Name * First Name Last Name Email * Date of Birth * Medical Issues * Medications Taking * Allergies * Previous clip or relate of tongue? What date? * Speech Issues * Others have a hard time understanding speech Embarrassed with communication Shy in social situations Difficulty speaking fast Difficulty getting certain words out Trouble with sounds Speech delay Stuttering Jaw gets tired when talking or reading aloud Speech harder to understand in long sentences Speech therapy Mumbling or speaking softly Difficulty singing Feeding Issues Breastfed or Bottle fed as a baby Fussy, colicky, or "difficulty" as a baby Frustrated when eating currently Slow eater (last one to finish a meal) Small appetite Graze on food throughout the day Pack food in cheeks Picky with textures Difficulty swallowing pills Choking or gagging on food or water Breathing Issues Trouble breathing through the nose Mouth open / mouth breathing during the day Tonsils or adenoids removed previously Sinus issues or sinus surgery Teeth extracted for braces Jaw surgery in the past Sleep Issues Sleep in strange positions move around a lot at night Wake easily or often Poor quality sleep Wake up tired and not refreshed Sleep appliance or CPAP needed at night Grind teeth while sleeping Sleep with mouth open Snore while sleeping Gasp for air or stop breathing (sleep apnea) Other Related Issues Neck or shoulder pain or tension TMJ pain, clicking or popping Headaches or migraines Strong gag reflex Prolonged thumb sucking Ear tubes previously or lots of ear infections Reflux Constipation Hyperactivity / Inattention Stress or anxiety Trouble or pain with kissing / intimacy Don't hold chiropractic adjustments well Not flexible / can't touch toes Anything else we need to know? Thank you!
