Other
Jaw Locking
Mairelated Arches
Difficulty Opening
Ear Pain
Restricted or Scalloped Tongue
Clenching or Grinding
Anxiety/Depression
Difficulty Focusing
Non-restorative Sleep
Voiding at Night (noctume)
Insomnia
Daytime Sleepiness
Headache
Facial Pain
Jaw Pain
Snoring
Adult Concerns: Place an "X" in the boxes that apply.
Other
Underdeveloped Maxila and/or Mandible
Tongue or Lip Tie
Speech
Irritable
Grinds Teeth
Crowded Teeth
Hyperactive
Restless
Night Terrors
Mouth Breathing
Bed Wetting
Snores
Night Sweats
Pediatric Concerns: Place an "X" in the boxes that apply.
For our dentists and doctors - please fill out this form to refer your patient to us!