Pediatric Myofunctional Evaluation Template

A fillable myofunctional evaluation for children about 2 and older with tethered oral tissues, covering speech, feeding and airway in one template.

Built by Meagan Dungan, M.S., CCC-SLP, this 18-page fillable PDF collects the baseline the NTX Myofunctional Therapy Protocol builds on. Exercise numbers 1 to 14 match all three protocol editions, so the baseline you record here is the same measure you track in therapy.

What's inside

1. Identifying information, referral, orders and concerns by area
2. A readiness screen: is the child ready for myofunctional therapy, or should you use the oral motor evaluation instead?
3. Medical, dental, orthodontic and developmental history
4. Airway and sleep history with a PSQ-SRBD field and referral guidance
5. Oral habits and prior release history
6. Provider team input: release provider, pediatrician, pediatric dentist, orthodontist, ENT, sleep medicine, allergy, PT/OT/bodywork, dietitian
7. Oral mechanism exam: rest posture, structure, occlusion, tonsils and function
8. Functional assessment of tethered oral tissues: lingual frenulum with TRMR measures, full upper labial frenulum assessment, lower labial and buccal frenula
9. Functional exam: airway and breathing
10. Functional exam: swallow and feeding, including tongue thrust and tongue base retraction
11. Functional exam: speech
12. Baseline of all 14 protocol exercises
13. Strength, range of motion and coordination ratings, objective measures, and tongue dissociation from the jaw and the floor of the mouth
14. Release readiness checklist and protocol phase placement
15. Clinical impressions, diagnosis and coding reminders
16. Goals, with a direct link to the NTX Goal Bank
17. Treatment plan: protocol edition, starting phase, release coordination, home program and discharge criteria
18. Medical necessity and functional impact
19. Caregiver education, consent and signatures

Also included: referral decision guides for ENT, airway and sleep and for tethered oral tissue release assessment.

Pairs with

• Myofunctional Therapy Protocol for Tethered Oral Tissues (3 Editions) ($97): treat from pre-release to discharge, in 3 kid-friendly editions.
• Pediatric Feeding & Myofunctional Goal Bank ($35): measurable goals for every deficit this evaluation documents.
• Save with the Myofunctional Evaluation + Protocol Bundle ($105) or the Complete Myofunctional Set ($135).

More from NTX

Every NTX resource is built to work with the others. Browse them all on the Therapist Resources page.

Feeding

• Comprehensive Pediatric Feeding Evaluation Template ($15): fillable feeding evaluation, birth to 18, with 5 referral decision guides.
• Gold Standard Pediatric Feeding Evaluation Report Guide ($47): report writing, 3 annotated sample reports, coding, plan of care kit and appeal letters.
• Feeding Evaluation + Report Bundle ($55): the feeding evaluation template and report guide.
• Complete Feeding Documentation Set ($85): feeding evaluation template, report guide and goal bank.

Oral motor (birth to about 2)

• Pediatric Oral Motor Evaluation Template ($19): fillable tethered oral tissue evaluation for birth to about 2: feeding, airway and pre-speech.
• Tiny Tongues Infant Oral Motor Protocol ($97): therapist-provided oral motor protocol for infants and young toddlers, with a parent home routine.
• Oral Motor Evaluation + Protocol Bundle ($105): the oral motor evaluation template and the Tiny Tongues protocol.
• Complete Oral Motor Set ($135): oral motor evaluation template, Tiny Tongues protocol and goal bank.

Instant download after checkout. Single-clinician license; please do not share or redistribute. Resources support, not replace, clinical judgment, your release provider's instructions and payer requirements.