Airways Academy Guidance Call - Intake Form

Thank you for booking a guidance call! Please take a few minutes to complete this form so we can make the most of our time together.

Basic Information:

First name

Last name

Country

Email

Phone

Instagram Handle

Who is this call for?

Age of the Person Needing Guidance

Year

Month

Day

Main Concerns & Goals:

What are your main concerns or goals for this call?

Medical & Airway History:

Have you or your child seen an ENT (ear, nose, and throat specialist)? (Y/N) If yes, what was discussed or recommended?

Have you or your child had any prior assessments or treatments for oral function? (Y/N) If yes, please provide details.

Has a healthcare provider ever mentioned concerns about breathing, tongue function, or facial development? (Y/N)

Do you or your child currently use any oral appliances (e.g., Myo Munchee, expander, orthodontics)? (Y/N) If yes, which ones?

Have you or your child had any feeding difficulties as a baby (e.g., trouble breastfeeding, reflux, difficulty with solids)? (Y/N)

Allergies, Diet & Inflammation:

Do you or your child have any known allergies or food intolerances? (Y/N) If yes, please list them.

Do you or your child frequently experience congestion, runny nose, or sinus issues? (Y/N)

Would you say you or your child consumes a lot of inflammatory foods? (Common examples: dairy, gluten, processed sugars, artificial additives, seed oils.) (Y/N)

Would you be open to making dietary adjustments if it could help? (Y/N)

Lifestyle & Daily Habits:

How do you or your child primarily breathe?

Nose

Mouth

Unsure

Did you/does your child use a pacifier or suck their thumb/fingers? (Y/N) If yes, how often?

Did you/does your child have any trouble eating certain textures or foods?

Yes

No

Do you or your child wake up feeling rested?

Yes

No

Unsure

Do you or your child grind their teeth at night?

Yes

No

Unsure

Do you or your child sleep with their mouth open?

Yes

No

Unsure

Do you or your child snore?

Yes

No

Unsure

Do you or your child wake up in the night to go pee/ wet the bed?

Yes

No

Unsure

Final Details:

Is there anything else you’d like us to know before the call?

Do you have any specific questions you’d like answered during the call?

If you have any photos or videos or documents you would like us to see, you may upload them here 👇

Add up to 6 files

I understand that this guidance call is for educational purposes only and does not provide medical advice, diagnosis, or treatment.

I understand that cancellations or rescheduling requests made less than 24 hours before my scheduled appointment are non-refundable, and I will lose my deposit.

I understand that Failure to complete payment within 7 days will result in a $30 late fee and suspension of all support

I understand my report will be emailed within 3 days of the session, but only once payment is received.

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Intake Form

Airways Academy Guidance Call - Intake Form

Basic Information:

Main Concerns & Goals:

Medical & Airway History:

Allergies, Diet & Inflammation:

Lifestyle & Daily Habits:

Final Details:

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