The Myofunctional Center, LLC

The Myofunctional Center, LLC Michale C Fetzik, BSN OMT 2548 N Maize Court, Suite 100 Wichita, Kansas 67205 316 706 7623

Referral

Date: ______Name of Patient: ______Child Age: ______Phone #: ______Referring Health Practitioner: ______email: ______

Conditions Identified: o Mouth Breathing o Malocclusions o Tongue Thrust – Anterior o Cavities and Gum Disease o Bi-lateral Tongue Thrust o Changes in Saliva o Tongue Tie Quality/Quantity o Lip Tie o Restricted Maxilla/High o Atypical Swallowing Palate o Oral Habits o Tongue Scalloping o Chewing Disorder o Craniofacial Dysfunctions o Facial Muscle Dysfunction o Allergic Shiners/Venous o Hypotonic Masseters Pooling Eustachian Tube Dysfunction o Speech Misarticulation (lisp) o Macroglossia o Tonsils/Adenoids o Abnormal Breathing o TMJD o Tinnitus o Sleep Disorders/ Sleep o Apnea o Infant Feeding Problems o Bruxism/Clenching o Forward Head Posture o Low Tongue Rest Posture o Open Mouth Posture o Snoring o o Has the patient had an airway screen? Y N o Has the patient had Cranial 3D imaging? Y N o Has the patient had a Sleep Study? Y N o o Doctor, what objectives do you hope to accomplish with Myofunctional Therapy? o o o o What is your timeline for treatment? o I’m waiting for you to finish therapy. o I’m willing to phase treatment in order to accommodate therapy. o I’m placing oral TMJ/ Sleep / Orthodontic appliance and need to coordinate therapy after treatment. o o Signature of Provider: ______Date: ______o Note to Provider: o The airway; both upper and lower must be clear before OMT can be started. If tonsils/adenoids, turbinates, septal deviation, asthma, upper airway resistance, or any other structural or functional process inhibits breathing, Myofunctional Therapy will be limited in success. OMT is dependent on the ability of the patient to breathe with the mouth closed and breathe habitually through the nose. o