Name

Date of Birth

Guardian

Address

Email

Phone Home

Referred by

Insurance Carrier

Member ID Group # Office Only

Patient SS number

Insurance garniture SS

Shirley Gutkowski, RDH, BSDH

Primary OMT Practitioner and

Breathing Re-training Instructor

1266 W. Main Street

Sun Prairie, WI 53590

608 318 2800

Name:_________________________________________

Primal Air, LLC OMT and Breathing Retraining

Client Intake and Health History

Date:

Name: DOB

Address: Phone: Cell:

Profession or school Wk Phone:

Referral Previous OMT

Orthodontic history Current Ortho: Y N

Dr. Years Dr. Years

Medical History (include, falls, accidents, medications, supplements)

Infancy (breastfeeding problems, failure to thrive, etc.)

Childhood (bedwetting, night terrors, talking in sleep, sleepwalking, speech therapy, etc.)

Adolescence

Teen years

Young adult

Adult

After age 40

Name:_________________________________________

Current medications Dose Application (injection,

pill, inhaler etc.)

Condition

Allergies (include symptoms rash/cough/etc.)

Seasonal

Home care products

Food Allergy

How do you relieve allergy

symptoms

Medications Essential oils Other

Surgery Tonsils? Adenoids? Palate or tongue

Name:_________________________________________

Can you swallow

Pills Thin Liquids Thick liquids Foods

Aches n Pains

Surgery and dates

Habits Retired date Ongoing # years

Thumb sucking Y N

Finger Y N

Blanket Y N

Clothing Y N

Cheek Y N

Tongue Y N

Pencil/Pen chew Y N

Nail chewing Y N

Clenching Y N

Leaning Y N

Lip licking Y N

Chewing gum Y N

Smoking Y N

Tobacco Y N

Marijuana Y N

Caffeine, energy drinks Y N

Alcohol (beer wine hard) Y N

Other Y N

Nutrition

Messy eating Y N Drooling Day or Night?

Speedy eating Y N Normal Breakfast (describe)

Gulping Y N

Hiccups Y N Normal Lunch (describe)

Gas Y N

Stomach ache Y N Normal Dinner (describe)

Bloating Y N

Name:_________________________________________

Activities

Sports

Clubs

Musical Instruments

Video

Injuries

Professional Health Care Team

Dentist Acupuncturist Dental hygienist

Physician Chiropractor Naturopath

ENT Craniosacral Therapist Nutritionist

Psychologist Counselor Psychiatrist

Athletic coach Athletic trainer Physical therapist

Massage therapist

What are you hoping for from this therapy?

Better looking face

Improved performance (run faster)

Get rid of tongue habit

Avoid braces again

Get rid of CPAP

Get rid of other habit

Sleep with spouse

Sleep all night

Not wet the bed

Reduce/eliminate medication

Reduce TMJ symptoms

Something else (describe)

Authorization for Release of Information:

This authorization or photocopy hereof, will authorize Shirley Gutkowski to obtain and furnish pertinent information regarding the

condition of ______________________________ while under her observation or treatment.

This information may be obtained from and/or released to:

Dentist_____________________________________Address__________________________email_______________

Orthodontist_________________________________Address__________________________email_______________

Chiropractor_________________________________Address__________________________email_______________

Physical Therapist ____________________________ Address_________________________ email_______________

Signature___________________________________________________Date________________________

Page 1 of 4

INFORMED CONSENT FORM

Primal Air, LLC OMT and Breathing Retraining

Treatment Type: Orofacial Myofunctional Therapy or Breathing Retraining

Principal Therapist: Shirley Gutkowski

Participant’s Printed Name:

Your health is extremely important to us at Primal Air, LLC. We know that many conditions

have an underlying airway or orofacial (mouth and face) component. Through the techniques we

teach you can expect some vague and some specific changes based on your abilities and

motivation to do the prescribed exercises or wearing the prescribed appliances.

The scope of OMT includes techniques for correcting:

• Abnormal non-nutritive sucking habits (thumb, finger, pacifier, etc.)

• Other detrimental orofacial habits

• Abnormal orofacial rest posture problems

• Abnormal neuromuscular patterns associated with inappropriate chewing and swallowing

• Abnormal functional breathing/posture patterns

• Abnormal swallowing patterns

By providing

• Sequential program of exercises to bring about normal oral function • Establish nasal breathing instead of mouth breathing

• Enhance growth and development of the face and mouth • Shorten orthodontic treatment time

• Help to prevent relapse of dental cases

• Help with TMD dysfunction by modifying intraoral stress • Help with OSA dysfunctional by modifying mandibular arch and tongue position

Section 2. Procedures

You will be instructed in the use of your mouth and face in new ways. You’ll use common and

uncommon products in common an uncommon ways to help you get new tracks in your brain

and strengthen the muscles of your face and tongue to work better. The ultimate goal is specific

to each individual however studies show improvements in sleep, breathing, asthma symptoms,

TMD and even develop a chiseled looking face like the vampires in the movies.

You’ll be asked to perform tasks, like repeating a series of words, and exercise the muscles of

the face as well as move your tongue in specifically designed ways.

Page 2 of 4

Section 3. Time duration of the treatment

The treatment is individual and is solely at the discretion of the patient. Those who practice the

techniques at the rate prescribed will have excellent results in a shorter period of time than those

who partially follow the regimen at a rate that approximates the prescribed time. Those who

cannot find time to do the exercises the prescribed rate will take even longer.

Because we’re working with so many habits the duration of time necessary to break and reform

the bad habits may take a year as very often new bad habits appear as the changes and growth

take place.

Example of a Time Duration Section

If you agree to take part, your involvement will last about one year. We’ll meet every week for

30 minutes for about 8 weeks. Then every two weeks for 8 weeks then once a month until we’re

satisfied with the results. You will be asked to return to the clinic or visit via the internet at least

15 times. Each visit will take approximately 30 minutes.

Section 4. Discomforts and risks

There are no known risks with orofacial myofunctional therapy or breathing retraining. There

may be some discomfort at times but shouldn’t be enough to take over the counter pain

medication.

Example of a Discomforts and Risks Section

During the breathing retraining you may feel a need or air, or air hunger, or in some extreme

cases panic for air. As there are no gadgets or machines used you will have total control over

how long your breath holds may last until we achieve a desired level.

During one phase of the OMT eating may take longer than usual and you may suffer some

embarrassment during meals with others.

Section 5. Potential Benefits

The benefits of OMT and breathing retraining include but are not limited to

Better quality sleep

Improved facial muscle tone

Page 3 of 4

Good resting posture of the face/mouth

In children,

• short duration for braces if necessary

• better behavior potential benefits to others

Better quality sleep for family

Section 6. Statement of Confidentiality

Your records at Primal Air, LLC will be kept in a secured area in a HIPAA compliant cloud

system. Your records collected for research purposes will be labeled with your patient number

only and your identifying marks on photographs will be pixelated and stored in a HIPAA

compliant cloud storage system. Anything used for teaching purposes will hide your identity and

location.

For research records sent to an outside entity, you will not be identified by name, Social Security

number, address, or phone number. The records may include your patient number and age at the

time of the record.

In the event of any publication or presentation resulting from the research, no personally

identifiable information will be shared.

Your permission for the use, retention, and sharing of your identifiable health information will

never retire or become obsolete. When appropriate for teaching purposes (didactic, written, or

other) will be used to educate others on the features you present with and how your treatment

plan worked. Any research information in your medical record will be kept indefinitely.

Section 8. Compensation for Participation

Should your records be used for research or teaching, there is no compensation available.

Epworth Sleepiness Scale

Name: ______________________________________________ Today’s date: _________________

Your age (Yrs): _______________ Your sex (Male = M, Female = F): ________

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just

tired?

This refers to your usual way of life in recent times.

Even if you haven’t done some of these things recently try to work out how they would have affected

you.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

It is important that you answer each question as best you can.

Situation Chance of Dozing (0-3)

Sitting and reading ________________________________________

Watching TV ________________________________________

Sitting, inactive in a public place (e.g. a theatre or a meeting) _________

As a passenger in a car for an hour without a break _________________

Lying down to rest in the afternoon when circumstances permit ________

Sitting and talking to someone __________________________________

Sitting quietly after a lunch without alcohol ________________________

In a car, while stopped for a few minutes in the traffic ________________

THANK YOU FOR YOUR COOPERATION

M.W. Johns 1990-97

___

___

___

___

___

___

___

Belafsky PC, Postma GN, and Koufman JA. Validity and reliability of the reflux symptom index (RSI).

Journal of Voice. 2002. 16(2): 274-277.

Within the last MONTH, how did the following problem affect you? 0 = No problem to

5 = Severe problem

1. Hoarseness or a problem with your voice 0 1 2 3 4 5

2. Clearing your throat 0 1 2 3 4 5

3. Excess throat mucous or postnasal drip 0 1 2 3 4 5

4. Difficulty swallowing food, liquids, or pills 0 1 2 3 4 5

5. Coughing after you ate or after lying down 0 1 2 3 4 5

6. Breathing difficulties or choking episodes 0 1 2 3 4 5

7. Troublesome or annoying cough 0 1 2 3 4 5

8. Sensations of something sticking in your throat or a lump in your throat 0 1 2 3 4 5

9. Heartburn, chest pain, indigestion, or stomach acid coming up 0 1 2 3 4 5

TOTAL

The Reflux Symptom Index (RSI)

Shirley Gutkowski, RDH, BSDH

Primary OMT Practitioner and

Breathing Re-training Instructor

1266 W. Main Street

Sun Prairie, WI 53590

608 318 2800

NIJMEGEN QUESTIONNAIRE for hyperventilation complaints date: (NQ) How frequently you experience each symptom, in the past weeks, by circling one of the erect lines.

Seldom Sometimes Often Very Often

Never I_______I_______I_______I_______I

1. Chest pain I_______I_______I_______I_______I 2. Feeling tense I_______I_______I_______I_______I

3. Blurred vision I_______I_______I_______I_______I 4. Dizziness I_______I_______I_______I_______I 5. Confusion, loosing contact with reality I_______I_______I_______I_______I 6. Fast or deep breathing I_______I_______I_______I_______I 7. Shortness of breath I_______I_______I_______I_______I 8. Tightness in the chest I_______I_______I_______I_______I 9. Bloated abdominal feelings I_______I_______I_______I_______I 10. Tingling of the fingers I_______I_______I_______I_______I 11. Cannot breathe deeply I_______I_______I_______I_______I 12. Stiffness in fingers or arms I_______I_______I_______I_______I 13. Stiffness around the mouth I_______I_______I_______I_______I 14. Cold hands or feet I_______I_______I_______I_______I 15. Thumping of the heart I_______I_______I_______I_______I 16. Anxiety I_______I_______I_______I_______I

Name: Age: male / female Medication: Main complaints: