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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.

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