Orofacial Myofunctional Screening Note

Patient Name: [Full name] DOB: [MM/DD/YYYY] MRN: [Medical record number] Date of Service: [MM/DD/YYYY] Provider: [Name, credentials] Clinic/Location: [Site] Referral Source: [self / dental / orthodontic / ENT / PCP / school / other]

Screening Scope and Purpose

[Brief statement clarifying screening scope] (State that this is a focused screening to identify risk indicators or signs that may be consistent with orofacial myofunctional disorder features and to determine whether further assessment or referral is warranted. Clarify that this screening is not a comprehensive evaluation and does not establish medical, dental, or orthodontic diagnoses.)

Chief Concern and Goals

Chief concern: [Patient or caregiver concern in their own words]

Screening goals: [Goals for this visit, e.g., determine need for full evaluation, identify airway concerns, identify appropriate referrals]

Relevant History

(Use brief, high-yield qualifiers. If history was not obtained for a domain, write "Not obtained" rather than leaving blank.)

• Airway/Sleep: [Snoring, witnessed apneas or gasping, restless sleep, mouth breathing day/night, chronic nasal congestion, daytime sleepiness or behavioral concerns] / [Denies] / [Not obtained]
• Feeding/Swallow: [Infants: latch concerns, prolonged feeds, milk leakage, poor weight gain; Children/Adults: texture selectivity, open-mouth chewing, prolonged meals, coughing or choking history] / [Denies] / [Not obtained]
• Speech/Resonance: [Articulation concerns, lisp, unclear speech, nasal quality concerns, history of speech therapy] / [Denies] / [Not obtained]
• Dental/Orthodontic: [Current or past orthodontic treatment, concerns raised by dentist or orthodontist, appliances present] / [Denies] / [Not obtained]
• Oral Habits: [Thumb/digit sucking, pacifier use, nail biting, lip biting, bruxism; include duration and frequency if known] / [Denies] / [Not obtained]
• Relevant Medical History: [Tonsil/adenoid status, allergies/asthma, prior frenotomy or frenectomy, craniofacial conditions, neurologic history] / [Not obtained]

Screening Methods

• Observation context: [seated / standing / supine], [at rest / during conversation / during tasks], [caregiver present: yes / no]
• Tasks completed: [Rest posture observation, breathing observation, oral mechanism screen, tongue mobility screen, frenulum visual screen, saliva swallow, water swallow, speech sample spot check]
• Standardized tools/questionnaires: [Name of tool, score, cutoff] (Only include if used.)

Screening Findings

(For each domain, indicate status and provide brief descriptive evidence for atypical findings. Avoid diagnostic labels outside scope of practice.)

Breathing/Airway Observations

• Status: [within expected limits / atypical / not screened / unable to assess]
• Predominant breathing at rest: [nasal / mouth / mixed]
• Lip posture at rest: [closed / intermittently open / persistently open]
• Audible or effortful breathing: [present / absent]
• Ability to maintain nasal breathing during quiet rest: [yes / no / intermittent]
• Description: [Brief descriptive evidence if atypical] (Omit if within expected limits.)

Oral Rest Posture

• Status: [within expected limits / atypical / not screened / unable to assess]
• Lip seal: [competent / with strain / incomplete]
• Jaw position at rest: [neutral / open / retracted / protruded]
• Tongue resting position: [palatal contact / low / forward / interdental]
• Tongue scalloping: [observed / not observed]
• Description: [Brief descriptive evidence if atypical] (Omit if within expected limits.)

Tongue Mobility Screen

• Status: [within expected limits / atypical / not screened / unable to assess]
• Elevation: [adequate / reduced / jaw assist observed]
• Lateralization: [adequate / reduced / asymmetric]
• Protrusion: [adequate / reduced / deviated]
• Compensations: [jaw assist / head movement / perioral strain / none]
• Functional impact: [Impact on rest posture, speech, or swallow if noted]

Frenulum Screen

• Status: [within expected limits / atypical / not screened / unable to assess]
• Visual appearance: [Descriptive observations of lingual frenulum] (Avoid grading unless using a validated tool.)
• Functional observations: [Function related to tongue movement] (Do not include procedure recommendations.)

Swallow Screen

• Status: [within expected limits / atypical / not screened / unable to assess]
• Saliva swallow observed: [yes / no]
• Water swallow observed: [yes / no]
• Observed signs: [anterior tongue thrust / perioral contraction / head movement / audible swallow / none]
• Safety concerns: [coughing / choking / wet voice / none] (If present, address in Red Flags section.)

Speech/Resonance Spot Check

(This is a spot check, not a full speech evaluation.)

• Status: [within expected limits / atypical / not screened / unable to assess]
• Sibilant production: [typical / interdental / lateral / other]
• Resonance quality: [balanced / hyponasal characteristics / hypernasal characteristics]
• Intelligibility: [Reported vs. observed summary]

Dentofacial Observations

(Descriptive observations only; do not assign orthodontic diagnoses or malocclusion classifications.)

• Status: [within expected limits / atypical / not screened / unable to assess]
• Observed features: [Open bite appearance, overjet appearance, crowding, high or narrow palate appearance, dental appliance present, other descriptive features]

Oral Habits Observed

• Status: [present / absent / reported only / not screened]
• Habits: [Thumb/digit sucking, pacifier use, nail biting, lip biting, bruxism, other]
• Frequency/duration/context: [If known]

Pain/TMJ Screen

(Record symptoms only; do not diagnose TMJ disorder.)

• Status: [symptoms reported / no symptoms / not screened]
• Symptoms: [Jaw pain, clicking, locking, headaches, jaw deviation observed] / [None]

Red Flags

(Only include this section when red flags are present; otherwise omit entirely.)

• Airway/Sleep: [Loud habitual snoring, witnessed apneas, gasping at night, severe chronic mouth breathing, significant daytime sleepiness] Urgency: [routine / expedited / urgent]
• Feeding/Swallow Safety: [Coughing, choking, recurrent pneumonia, wet voice after swallowing, poor infant weight gain] Urgency: [routine / expedited / urgent]
• Structural concerns: [Description if noted] Urgency: [routine / expedited / urgent]
• Action taken today: [Safety counseling provided, immediate referral placed, sent to urgent care/ED, caregiver advised to contact provider today, other]

Screening Impression

Overall screening result: [Screen negative for OMD features today / Screen positive for OMD features with comprehensive evaluation recommended / Inconclusive with rescreen or evaluation recommended]

[Domain-based summary addressing airway/breathing, rest posture, swallow pattern, speech/resonance, dentofacial interface, and habits as relevant] (Use scope-appropriate language such as "findings may be consistent with," "screen suggests risk for," or "cannot rule out." Do not infer medical or dental diagnoses.)

Recommendations and Plan

• Comprehensive Orofacial Myofunctional Evaluation: [indicated / not indicated], [timeframe if applicable]
• Referrals: [ENT, sleep medicine, allergy, dentist, orthodontist, lactation consultant, pediatric provider, other] (List referrals recommended or placed. If referral cannot be placed, document that patient/caregiver will contact appropriate provider and include any safety instructions.)
• Patient Education: [Brief summary of counseling provided]
• Follow-up: [Timeline and materials to bring to next visit]

Shared decision-making: [Patient/caregiver understanding, agreement, and questions addressed]

Signature

Provider Signature: [Signature] Credentials: [Credentials] Date/Time Signed: [MM/DD/YYYY HH:MM]