{"product_id":"myofunctional-evaluation-template","title":"Pediatric Myofunctional Evaluation Template","description":"\u003cp\u003e\u003cstrong\u003eA fillable myofunctional evaluation for children about 2 and older with tethered oral tissues, covering speech, feeding and airway in one template.\u003c\/strong\u003e\u003c\/p\u003e\n\u003cp\u003eBuilt 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.\u003c\/p\u003e\n\u003ch3\u003eWhat's inside\u003c\/h3\u003e\n\u003col\u003e\n\u003cli\u003eIdentifying information, referral, orders and concerns by area\u003c\/li\u003e\n\u003cli\u003eA readiness screen: is the child ready for myofunctional therapy, or should you use the oral motor evaluation instead?\u003c\/li\u003e\n\u003cli\u003eMedical, dental, orthodontic and developmental history\u003c\/li\u003e\n\u003cli\u003eAirway and sleep history with a PSQ-SRBD field and referral guidance\u003c\/li\u003e\n\u003cli\u003eOral habits and prior release history\u003c\/li\u003e\n\u003cli\u003eProvider team input: release provider, pediatrician, pediatric dentist, orthodontist, ENT, sleep medicine, allergy, PT\/OT\/bodywork, dietitian\u003c\/li\u003e\n\u003cli\u003eOral mechanism exam: rest posture, structure, occlusion, tonsils and function\u003c\/li\u003e\n\u003cli\u003eFunctional assessment of tethered oral tissues: lingual frenulum with TRMR measures, full upper labial frenulum assessment, lower labial and buccal frenula\u003c\/li\u003e\n\u003cli\u003eFunctional exam: airway and breathing\u003c\/li\u003e\n\u003cli\u003eFunctional exam: swallow and feeding, including tongue thrust and tongue base retraction\u003c\/li\u003e\n\u003cli\u003eFunctional exam: speech\u003c\/li\u003e\n\u003cli\u003eBaseline of all 14 protocol exercises\u003c\/li\u003e\n\u003cli\u003eStrength, range of motion and coordination ratings, objective measures, and tongue dissociation from the jaw and the floor of the mouth\u003c\/li\u003e\n\u003cli\u003eRelease readiness checklist and protocol phase placement\u003c\/li\u003e\n\u003cli\u003eClinical impressions, diagnosis and coding reminders\u003c\/li\u003e\n\u003cli\u003eGoals, with a direct link to the NTX Goal Bank\u003c\/li\u003e\n\u003cli\u003eTreatment plan: protocol edition, starting phase, release coordination, home program and discharge criteria\u003c\/li\u003e\n\u003cli\u003eMedical necessity and functional impact\u003c\/li\u003e\n\u003cli\u003eCaregiver education, consent and signatures\u003c\/li\u003e\n\u003c\/ol\u003e\n\u003cp\u003eAlso included: referral decision guides for ENT, airway and sleep and for tethered oral tissue release assessment.\u003c\/p\u003e\n\u003ch3\u003ePairs with\u003c\/h3\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/myofunctional-therapy-protocol\"\u003eMyofunctional Therapy Protocol for Tethered Oral Tissues (3 Editions)\u003c\/a\u003e ($97): treat from pre-release to discharge, in 3 kid-friendly editions.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/pediatric-feeding-myofunctional-therapy-goal-bank\"\u003ePediatric Feeding \u0026amp; Myofunctional Goal Bank\u003c\/a\u003e ($35): measurable goals for every deficit this evaluation documents.\u003c\/li\u003e\n\u003cli\u003eSave with the \u003ca href=\"\/products\/myofunctional-evaluation-protocol-bundle\"\u003eMyofunctional Evaluation + Protocol Bundle\u003c\/a\u003e ($105) or the \u003ca href=\"\/products\/complete-myofunctional-set\"\u003eComplete Myofunctional Set\u003c\/a\u003e ($135).\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003ch3\u003eMore from NTX\u003c\/h3\u003e\n\u003cp\u003eEvery NTX resource is built to work with the others. Browse them all on the \u003ca href=\"\/collections\/therapist-education\"\u003eTherapist Resources\u003c\/a\u003e page.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeeding\u003c\/strong\u003e\u003c\/p\u003e\u003cul\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/pediatric-feeding-evaluation-template\"\u003eComprehensive Pediatric Feeding Evaluation Template\u003c\/a\u003e ($15): fillable feeding evaluation, birth to 18, with 5 referral decision guides.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/pediatric-feeding-evaluation-report-writing-guide\"\u003eGold Standard Pediatric Feeding Evaluation Report Guide\u003c\/a\u003e ($47): report writing, 3 annotated sample reports, coding, plan of care kit and appeal letters.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/feeding-evaluation-report-bundle\"\u003eFeeding Evaluation + Report Bundle\u003c\/a\u003e ($55): the feeding evaluation template and report guide.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/complete-feeding-documentation-set\"\u003eComplete Feeding Documentation Set\u003c\/a\u003e ($85): feeding evaluation template, report guide and goal bank.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003e\u003cstrong\u003eOral motor (birth to about 2)\u003c\/strong\u003e\u003c\/p\u003e\u003cul\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/oral-motor-evaluation-template\"\u003ePediatric Oral Motor Evaluation Template\u003c\/a\u003e ($19): fillable tethered oral tissue evaluation for birth to about 2: feeding, airway and pre-speech.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/tiny-tongues-infant-oral-motor-protocol\"\u003eTiny Tongues Infant Oral Motor Protocol\u003c\/a\u003e ($97): therapist-provided oral motor protocol for infants and young toddlers, with a parent home routine.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/oral-motor-evaluation-protocol-bundle\"\u003eOral Motor Evaluation + Protocol Bundle\u003c\/a\u003e ($105): the oral motor evaluation template and the Tiny Tongues protocol.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/complete-oral-motor-set\"\u003eComplete Oral Motor Set\u003c\/a\u003e ($135): oral motor evaluation template, Tiny Tongues protocol and goal bank.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eInstant 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.\u003c\/p\u003e","brand":"NTX Feeding \u0026 Myofunctional Therapy Institute","offers":[{"title":"Default Title","offer_id":44688226779214,"sku":null,"price":19.0,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0768\/0458\/7598\/files\/NTX-Myofunctional-Eval-Cover_9cd5621a-6653-4f24-8845-fc108121813e.jpg?v=1793131718","url":"https:\/\/ntxfeedingandmyo.com\/products\/myofunctional-evaluation-template","provider":"NTX Feeding \u0026 Myofunctional Therapy Institute","version":"1.0","type":"link"}