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DO YOU OR YOUR CHILD HAVE A TONGUE TIE?

Not sure which program is right for you or your child??

This questionnaire is to help provide insight into potential symptoms or difficulties associated with tongue ties. It is meant to gather preliminary information, to help guide you to the appropriate program, in order to help you achieve the goals of Myofunctional Therapy, and to have full support if a tongue tie release is required.  This should not replace a professional assessment by a healthcare provider for a proper diagnosis and treatment plan.

 

Press the button below to start the Questionnaire.

 

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Question 1 of 9

Do you or your child have any of the following medical conditions or concerns?  Select all that apply:

(Select all that apply)
A

High blood pressure

B

Diabetes

C

Asthma/ other respiratory disorders

D

Allergies

E

Acid Reflux

F

Sleep Apnea

G

Nasal obstruction (unable to breath through one or both nostrils)

H

Chronic congestion

I

ADHD/ ADD

J

None of the above

Question 2 of 9

The following is a list of symptoms related to speech. Please select all relevant symptoms that you or your child experience, either past or current:

(Select all that apply)
A

Delayed speech

B

Mumble, stutter, or lack clarity

C

Speak with a lisp

D

Have difficulty pronouncing certain sounds or words

E

Get frustrated, and people have a hard time understanding you or your child

F

Have concerns with speech and/or had speech therapy

G

None of the above

Question 3 of 9

Please select any that apply to your child when feeding as a baby:

(Select all that apply)
A

Baby would make smacking or clicking sounds while breasfeeding

B

Baby would "cluster feed". Eat often for short periods of time

C

Baby would spit up, or drool often while feeding

D

Baby would choke or gag while feeding

E

Baby was fussy, or colic

F

Baby had a shallow, painful latch

G

Mom would have sore, cracked, or bleeding nipples

H

Mom had inadequate milk supply, or incomplete milk drainage

I

None of the above

J

I don't know

Question 4 of 9

Please select all gastrointestinal symptoms that apply to you or your child, past or current, following meals:

(Select all that apply)
A

Acid Reflux

B

Heartburn/ indigestion

C

Gas/ Burping

D

Stomach aches/ pain

E

Hiccupping

F

Bloating/ discomfort

G

None of the above

Question 5 of 9

Regarding sleep, and/or sleep behaviors, please select all that apply to you or your child:

(Select all that apply)
A

Mouth breath day and/or night

B

Snores

C

Still feels or appears tired in the morning

D

Restless, sleeps in awkward positions

E

Resists going to bed/ takes a long time to fall asleep

F

Wakes up often through the night

G

Bedwetting

H

Emotional outbursts

I

Often irritable, short, or angry

J

Aggressive or argumentative

K

None of the above

Question 6 of 9

 

Do you or your child have an open bite, similar to above image; and/or do you notice the tongue thrusting forward when swallowing?

A

No

B

Yes

C

Tongue thrusts forward, but no open bite present.

Question 7 of 9

When lifting the tongue, do you or your child have a similar appearance to any of the images provided? 

                           

A

YES

B

NO

Question 8 of 9

When sticking the tongue out or moving it side to side, can you or your child relate to any of these images below?

    

Depression in the middle tongue, and/or a deep midline groove;

 

Deep midline groove, and/or a heart shaped tip;  

  Limited extension and/or a heart shaped tip;

   

Tongue pushes into the lower lip and/or limited extension;

  

Tongue pushes into and/or drags across lower lip during lateralization with limited mobility;

 the jaw moves with the tongue when moving it side to side, and/or a heart shape tip during lateralization.

(Select all that apply)
A

Heart shaped tip during lateralization or extension

B

A deep depression or midline groove

C

Limited on extension or lateralization

D

Tongue pushes into the lower lip

E

Jaw moves with the tongue during lateralization

F

None of the above

Question 9 of 9

Please select all that apply to you or your child, either past or current:

(Select all that apply)
A

Orthodontic treatment/ or relapse

B

A narrow palate

C

Crooked teeth, overbite, or retruded lower jaw

D

TMJ/ TMD Symptoms

E

Headaches/ migraines

F

Clenching, or grinding

G

None of the above

Confirm and Submit