Home Exercise Program (Myofunctional Therapy)

Patient Name: [Patient name]

Date of Birth: [Date of birth]

Date: [Date]

Provider: [Provider name and credentials]

Location: [Clinic / Telehealth]

Program Overview

Focus Areas: [Patient-friendly functional targets in 1–2 sentences, e.g., resting tongue position, nasal breathing, gentle lip seal, swallow pattern] (Include only targets discussed with the patient.)

Goals: (List 1–3 achievable targets with timeframes when known.)

• [Goal with timeframe]
• [Goal with timeframe] (Include only if applicable.)
• [Goal with timeframe] (Include only if applicable.)

Daily Commitment: [Total minutes per day, number of sessions, and timing; include setup notes such as mirror, quiet space, clean hands] (Do not leave blank.)

Exercises

(Order exercises from foundational awareness/breathing to tongue/lip control to integration. Duplicate or remove exercise blocks as needed.)

[Target Area: Nasal Breathing / Posture Awareness / Tongue Posture / Lip Seal / Swallow Pattern / Nighttime Supports]

[Exercise Name]

Purpose: [1–2 sentence rationale in plain language; explain benefit without promising outcomes]

Starting Position: [Brief posture and tongue/lip placement to begin]

Steps:

1. [First action using simple verbs: Place, Press, Hold, Relax, Breathe]
2. [Next action]
3. [Next action or hold with time]
4. [Return to rest or complete the repetition]

Dose: [Reps × sets, hold time in seconds, times per day] (Be specific; do not leave blank.)

Cues:

• [Reminder, e.g., keep lips gently closed]
• [Reminder, e.g., breathe through your nose]
• [Reminder or what patient should feel] (Include 2–4 cues.)

Common Mistakes:

• [Typical error with brief correction]
• [Second error with correction] (Include only if applicable.)

[Target Area]

[Exercise Name]

Purpose: [1–2 sentence rationale]

Starting Position: [Brief starting position]

Steps:

1. [Action]
2. [Action]
3. [Action]
4. [Return to rest or complete the rep]

Dose: [Reps × sets, hold time, frequency per day]

Cues:

• [Cue]
• [Cue]
• [Cue] (Include only if helpful.)

Common Mistakes:

• [Mistake with correction]
• [Mistake with correction] (Include only if applicable.)

[Target Area]

[Exercise Name]

Purpose: [1–2 sentence rationale]

Starting Position: [Brief starting position]

Steps:

1. [Action]
2. [Action]
3. [Action]
4. [Return to rest or complete the rep]

Dose: [Reps × sets, hold time, frequency per day]

Cues:

• [Cue]
• [Cue]
• [Cue] (Include only if helpful.)

Common Mistakes:

• [Mistake with correction]
• [Mistake with correction] (Include only if applicable.)

Equipment: [List items needed, e.g., mirror, timer, tongue depressor, straw, myofunctional device, or state "No equipment needed"]

Safety and Precautions

Stop and contact the clinic if you experience: worsening pain, new jaw locking, bleeding, swelling, dizziness, or any concerning symptoms.

Patient-Specific Precautions: [Recent oral surgery guidance, TMJ/jaw discomfort modifications, braces/appliance considerations, nasal obstruction notes, pediatric supervision needs] (Omit this line entirely if no precautions apply.)

Barriers and Strategies

(Do not leave blank. Document at least one barrier–strategy pair discussed and agreed upon.)

• Barrier: [Identified barrier, e.g., time constraints, forgetfulness, discomfort] — Strategy: [Agreed approach, e.g., pair with toothbrushing, set phone alarms, shorter sessions]
• Barrier: [Identified barrier] — Strategy: [Agreed approach] (Include additional pairs as discussed.)

Follow-Up

Next Visit: [Scheduled date/time or recommended timeframe]

Contact: [Clinic phone number and/or patient portal instructions]

When to Call Sooner: [Specific symptoms or concerns warranting earlier contact] (Include only if clinically indicated.)

Education Verified: [Teach-back confirmation, e.g., patient demonstrated exercises correctly and verbalized key cues] (Include only if education was provided and understanding was verified.)

Plan Version: [Date or version number] — [Brief changelog if updated: exercises added, removed, or modified]