Orofacial Myofunctional Evaluation Report

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Date of Evaluation: [Evaluation date]

Clinician: [Clinician name, credentials, certifications]

Referring Provider: [Referring provider name and credentials]

Reason for Referral: [Referral reason stated by provider]

(Maintain clear source attribution throughout: label content as reported by patient/caregiver, chart-documented, or observed in session. When a clinically expected domain was not assessed or information was not obtained, state this explicitly rather than omitting the section. Use descriptive, scope-appropriate language; avoid diagnosing medical or dental conditions outside SLP scope. Omit subsections that are clearly inapplicable to the patient population.)

Chief Concern

Patient/Caregiver Statement: [Primary concern in their own words] (Use quotation marks if direct quote is available.)

Clinician Restatement: [Brief restatement of functional question driving evaluation]

Primary Functional Impacts: [Functional impacts such as breathing, sleep quality, feeding efficiency, speech intelligibility, drooling, oral fatigue] (Include 2–4 items as applicable.)

Evaluation Methods

Informants and Sources: [patient / caregiver / chart review / other]

• Procedures Completed: [Procedures performed] (e.g., case history interview, observation of rest posture and function, oral mechanism exam, swallow/feeding observation, speech sampling, standardized measures)
• Standardized Tools Used: [Tool name, version, and date administered] (Include only if administered.)
• Foods/Liquids Observed: [Consistencies observed] (Include only if swallow/feeding was assessed.)
• Validity and Representativeness: [Cooperation level; whether findings reflect typical function; any limiting factors]
• Procedures Not Completed: [Procedures not completed with rationale] (State "None" if all planned procedures were completed.)

Relevant History

Medical and Developmental History

• Patient/Caregiver Report: [Pertinent diagnoses affecting tone, coordination, or sensation; allergies; chronic congestion; relevant medications; surgical history related to airway, feeding, or speech; birth history and developmental milestones for pediatric patients]
• Chart-Documented: [Relevant diagnoses, medications, procedures, or consult notes] (State "None found in chart" or "Not reviewed" if applicable.)

Airway, Breathing, and Sleep History

• Patient/Caregiver Report: [Nasal obstruction symptoms; mouth breathing patterns day/night; snoring frequency and severity; witnessed pauses or gasping; restless sleep; daytime fatigue or attention concerns; prior ENT findings; current airway supports]
• Screening Measures: [Questionnaire name and score] (Screening tools are not diagnostic. Include only if administered.)
• Chart-Documented: [ENT, sleep, or dental notes relevant to airway] (State "Unknown" if not available.)

Dental and Orthodontic History

• Orthodontic Status: [Current stage, appliances, compliance]
• Dental Concerns: [Relevant findings as reported]
• Oral Habits with Dental Implications: [Bruxism, clenching, or other habits with frequency and context]

Feeding and Swallow History

• Feeding Development: [Breast/bottle history; texture progression] (Include only for pediatric patients.)
• Current Diet and Textures: [Typical foods and liquids; restrictions or preferences]
• Mealtime Efficiency: [Duration; fatigue signs; need for breaks]
• Oral Phase Concerns: [Pocketing; anterior spillage; messy eating]
• Airway Protection History: [Coughing or choking frequency and context; wet voice; pneumonia history] (If history suggests aspiration risk, document prominently and recommend medical evaluation.)
• Drinking Skills: [Cup and straw skills; control]
• Chewing Patterns: [Side preference; efficiency; fatigue]
• GI/Reflux Symptoms: [Relevant symptoms and management] (Include only if relevant.)

Oral Habits

• Digit/Pacifier Use: [Current or past; duration and frequency]
• Nail/Lip Biting: [Frequency and context]
• Rest Posture Habit: [Habitual open-mouth posture observations]
• Parafunctional Behaviors: [Daytime clenching; sleep bruxism; other behaviors with frequency]

Prior Therapy

• SLP/OT/Myofunctional Therapy: [Dates; goals addressed; outcomes; adherence] (State "None reported" if applicable.)

Clinical Examination

General and Extraoral Observations

• Overall Posture: [Head, neck, and shoulder alignment]
• Alertness/Behavioral State: [alert / cooperative / distractible / fatigued]
• Breathing Pattern at Rest: [nasal / oral / mixed]
• Lip Seal at Rest: [closed / parted] (Note habitual vs. cued.)
• Facial Symmetry and Tone: [Observations]
• Mentalis Activation: [present / absent] [Context if present]
• Jaw Posture: [relaxed / tense] [Deviations if noted]
• Drooling: [none / occasional / frequent] [Context]

Intraoral Examination

• Palate: [Shape and arch observations]
• Dentition/Spacing: [Descriptive observations without diagnosing occlusion]
• Tongue: [Size, appearance, scalloping if present]
• Tonsillar Tissue Visibility: [Descriptive visibility]
• Oral Mucosa: [Hydration and observations]

Frenulum Screening

(Include only when concern exists. Describe structure and function without over-precise classification.)

• Functional Signs: [Tongue elevation or protrusion limitations; compensatory jaw movement; inability to achieve lingual-palatal seal; pain or tension behaviors]
• Structural Appearance: [Appearance under elevation described neutrally]
• Functional Impact: [How limitations relate to feeding, speech, rest posture, or sleep concerns]
• Referral Recommendation: [Consider evaluation by (provider type) to assess structure and function]

Oral Motor Function

• Lip Function: [ROM; seal; coordination; symmetry; endurance]
• Tongue Function: [Elevation; lateralization; protrusion; dissociation from jaw; coordination; strength and endurance with method]
• Jaw Function: [Opening and closing ROM; grading; stability; deviations]
• Cheek Function: [Tone; ROM; coordination]
• Diadochokinesis: [AMR/SMR rates; precision, rhythm, and fatigue observations] (Include only if assessed.)

Rest Posture and Breathing Assessment

(Core section. Quantify observations when possible.)

• Lip Position at Rest: [closed / open] [Approximate % of observation time]
• Tongue Position at Rest: [palatal / low / forward] [Approximate % of observation time]
• Jaw Position at Rest: [relaxed / tense] Teeth: [slightly apart / contact / clenched]
• Breathing Mode at Rest: [nasal / oral / mixed] [Approximate % of observation time]
• Breathing Mode During Conversation: [nasal / oral / mixed]
• Nasal Patency Screening: [Airflow ease or obstruction; unilateral vs. bilateral]
• Sustained Nasal Breathing and Lip Seal: [able / not able] [Duration without cues] [Duration with cues] (Note fatigue or compensations.)

Swallow and Feeding Observation

(Include when swallowing or feeding was observed. State "Not assessed" if not performed.)

Saliva Management

• Spontaneous Swallow Frequency: [infrequent / typical / frequent]
• Drooling: [none / occasional / persistent] [Context]
• Tongue Position at Swallow Initiation: [palatal / low / forward]
• Compensations: [Lip or jaw contractions; head movement]

Nutritive Swallowing

(Document by bolus type observed. If aspiration signs are observed, document immediate safety actions and recommend dysphagia evaluation.)

• Thin Liquid:
  • Delivery Method: [cup / straw / bottle / spoon]
  • Oral Phase: [Anterior spillage; pocketing; residue; preparation efficiency]
  • Swallow Pattern: [Tongue thrust; perioral contraction; jaw stabilization]
  • Airway Protection Signs: [none / cough / throat clear / wet vocal quality] [Actions and recommendations if concerns noted]
• Thick Liquid: [Observations as above] (Include only if observed.)
• Puree: [Observations as above] (Include only if observed.)
• Soft Solid: [Observations as above] (Include only if observed.)
• Regular Solid: [Observations as above] (Include only if observed.)

Speech Assessment

(Include when speech was assessed. State "Not assessed" if not performed. Use language such as "may contribute to" rather than implying single-cause relationships.)

• Speech Sample Context: [conversation / reading / repetition / picture description]
• Articulation Patterns: [Observations of sibilants, lingual-alveolars, interdentalization, lateralization]
• Resonance Observations: [balanced / hyponasal quality / hypernasal quality]
• Intelligibility: [Estimate and functional impact]
• Standardized Testing: [Tool name; scores; interpretation] (Include only if administered.)

Standardized Measures

(Include when administered. If none, briefly note reason and describe observational baselines used.)

• Instrument: [Tool name, version, and date]
• Scores: [Subdomain and total scores; severity classification if defined]
• Interpretation: [Brief interpretation; note norms and applicability limitations]
• Objective Measures: [Device, protocol, and values] (Include only if obtained.)

Clinical Impressions

Summary

[3–6 sentence narrative integrating most clinically significant findings with functional implications] (Use scope-appropriate phrasing such as "Findings are consistent with orofacial myofunctional pattern differences impacting..." Note uncertainties and evaluation limits.)

Problem List

(List in order of functional significance or medical risk.)

• [Problem 1]:
  • Supporting Evidence: [Observed signs and test findings]
  • Functional Impact: [Impact on breathing, sleep, feeding, speech, or other functions]
  • Clarification Needed: [Referral or additional evaluation to confirm or define severity]
• [Problem 2]: [As above] (Add additional problems as needed.)

Contributing Factors

[Factors maintaining problems such as airway obstruction, oral habits, structural limitations, orthodontic status, or sensory and behavioral factors]

Referrals

(Include when indicated.)

• Provider: [ENT / sleep medicine / allergist / orthodontist / dentist / pediatrician / other]
• Reason: [Functional concern with supporting findings]
• Urgency: [routine / soon / urgent]
• Communication Plan: [Contact method and timeline; ROI status]

Recommendations

• Immediate: [Safety steps; education provided; environmental adjustments] (Emphasize that medical evaluation for airway or sleep concerns should precede intensive myofunctional exercises.)
• Next 2–4 Weeks: [Home program focus; behavioral strategies; habit awareness]
• Longer-Term: [Therapy themes; coordination with other providers; re-evaluation timing]
• Patient/Caregiver Understanding: [Teach-back confirmation; agreed next steps]

Plan of Care

(Include when therapy is initiated. If not initiating therapy, state rationale such as pending medical evaluation or consultation-only.)

• Frequency and Duration: [Sessions per week; minutes per session; anticipated visits; re-evaluation interval]
• Long-Term Functional Goals:
  • [Behavior; condition/support level; criterion; timeframe]
  • [Behavior; condition/support level; criterion; timeframe]
• Short-Term Measurable Goals:
  • [Behavior; condition/support level; criterion; timeframe]
  • [Behavior; condition/support level; criterion; timeframe]
• Intervention Plan: [Planned intervention categories such as nasal breathing training, oral rest posture, tongue-jaw dissociation, swallow pattern training, habit elimination, carryover]
• Outcome Measures for Re-evaluation: [Observational metrics or standardized measures to track change]

Prognosis

• Prognosis: [good / fair / guarded] [Brief rationale]
• Facilitators: [Motivation; caregiver involvement; responsiveness to cues; access to care]
• Barriers: [Untreated nasal obstruction; structural limitations; adherence concerns; competing priorities]

Clinician Signature: [Signature]

Credentials: [Credentials and certifications]

Date: [Date signed]