OMT & Breathing Retraining at Primal Air - Primal Air - Shirley … · 2018-01-09 · Primal Air,...
Transcript of OMT & Breathing Retraining at Primal Air - Primal Air - Shirley … · 2018-01-09 · Primal Air,...
Name
Date of Birth
Guardian
Address
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________________________
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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.
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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
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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
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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: