Please tell me about yourself and answer as many of the following questions as you can, be as
detailed as possible.  Your full identity will never be disclosed without your permission.

Optional:  Full name address and phone number:

First Name:


Phone Number:                               

City, State:

How old are you?

Male or Female?  

1. Is there anyone else in your family that chews on their tongue including grandparents?

2. Does anyone in your family have other habits that you know about? Who?

3. What is your earliest memory of chewing on your tongue How old were you?

4. Describe the intensity of your chewing ( 0=very mild   5=very intense).                   

5. Do you chew your tongue in your sleep?  

6. Do you chew your tongue lying down.  (please try it)?

7. Are your teeth straight,  (Front/Back)  look in the mirror to see your back teeth

8. How much room do you have for your tongue? Try taking a teaspoon the round side (the back) facing up, placing it between your
upper teeth so that it rests against the roof of your mouth. Do the same with your lower teeth, round side down, pressing against
your tongue.    Does it fit?

9. Have you ever worn dental orthopedics or braces, when and for how long?

10. Have you had any teeth extracted?   When?    Which ones?    Why?

11. Do you grind your teeth?

12. When your jaw is in the relaxed position, where does your tongue and the tip of your tongue rest?

13. Where does the tip of your tongue rest, when you gently bite down?

14. When you gently bite down, do your teeth evenly come together?
(Bite down and glide your tongue gently around the inside of your teeth, are there any gaps?)

15. When you swallow, where is the tip of your tongue during the process?

16. When you breathe naturally, is your mouth open or closed?

17. Do you breathe through your mouth?

18. Do you often have difficulty breathing just through your nose?

19. Describe any dental issues?

20. What percentage (%) of the day do you chew your tongue?
Example: I chew my tongue about 50% of the day, but only when I'm alone.

21. How aware of the tongue chewing are you?

22. How much control do you have or how long can you suppress the urge to chew?

23.  If you suppress the chewing do you feel there is a buildup urge that is relieved from doing it?  Please try to explain?

24.  How do you stop or control your chewing?

25. If you have chewing gum in your mouth do you chew on your tongue.

26. If you were to place a toothpick between your lips, does it stop you from chewing on your tongue?

27. Do you make any vocal sounds when you chew such as singing or humming?

28. Do you have any clicking or popping in your Jaw?

29. Does your chewing cause you any pain?
Describe the pain.

30. How embarrassing is this habit for you?

31. Have you ever told anybody about this habit?

32. When do you
not chew on your tongue?  

33. Do you chew in public or with family?

34. Has there ever been a time that you remember that you stopped chewing on your tongue for a period of time?

35. Did you ever suck your thumb, until what age? Do you remember how you stopped?

36. Do you remember if you started chewing on your tongue before or after you stopped sucking your thumb?

37. Describe any sensations you get in your tongue, jaw or neck.  

38. Can you remember any significant accident, fall or emotional event that corresponds to the time you started chewing?

39. What makes your chewing worse or when do you chew the most?

40. Do you get pleasure or enjoyment from chewing?  

41. Have you ever been diagnosed or treated for this condition?
If yes please explain.

42. Please describe your chewing behavior pattern.
Example: I only bite on the left side of my tongue.
Example: I chew from side to side and my tongue often protrudes from my mouth.
Example: I really don't chew, I actually bite parts of my tongue until it bleeds.

43. Do you know anything about your birth or any problems as an infant?  

44. List any prescription medications you may have taken before you started to chew you tongue? When and for how long?

45. Do you have any other conditions or habits including ADD (Attention Deficit Disorder) or speech problems?

46. Do you have any memory problems?
If yes please describe?

Additional comments:

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