For professionals
Diagnostic form for FaceFormer therapyThe assessment form to download
For speech therapy, orthodontics, dentistry and physiotherapy. Here you can download the assessment form and find out what it records about breathing, swallowing and head balance, how to use it in your practice, how to document progress with it and where its limits lie.
The key points at a glance
- The form is a screening of the basic functions of breathing, swallowing and head balance, structured according to the Cranio-Cervical Functional Model (CCFM). It is available as an interactive PDF with automatic scoring and as a print version.
- What is meaningful is not the individual sign, but the combined occurrence of several signs. The form organises a functional assessment; it does not measure and does not replace a medical diagnosis.
- Used repeatedly, it shows intermediate steps in the basic functions before a complaint changes. Completed forms stay in your practice.
Download
The diagnostic form as a PDF
The form is available in two versions with the same content. Choose the one that suits your documentation.
Interactive version
You fill in the form on screen, and the form itself calculates the points per section and the totals. You then print or save the result.
Download interactive PDF
Print version
For printing and filling in by hand; you count the points yourself. Practical if you document on paper in the treatment room.
Download print PDF
For the interactive version you need a PDF reader that supports form fields and calculations, for example the free Adobe Acrobat Reader or Foxit PDF Reader. Browser previews and some apps do not show the automatic totals. In that case, use the print version.
Both files have nine pages. The form begins with personal details, previous illnesses, current medication and a note of who carried out the assessment. This is followed by eight assessment sections with 48 features and a ninth with 14 groups of complaints. You tick every feature that applies, and each tick counts as one point.
A picture chart at the end shows an example for many of the features, such as tooth impressions on the edge of the tongue or the so-called pincushion chin. This way, different examiners assess the same sign against the same reference.
Context
What the form is intended for
It is called a diagnostic form. By design, it is an assessment and screening form for the basic functions.
The form records whether the constitutively dominant functions are impaired. This refers to breathing, swallowing and head balance, the basic functions which, in our view, are at the root of many complaints in the head and neck region. It does not replace a medical diagnosis. It gives you a structured functional assessment that can be read across disciplines.
The sum of the findings would be a list. Their combination is the information.Tooth impressions on the edge of the tongue or an open mouth can also occur on their own, with a cold, after long hours of screen work or with no complaints at all. Only several signs together form a pattern.
This results in three tasks. The form organises the baseline assessment before training begins. It makes the conversation with patients concrete, because they see their own signs. And it serves for progress diagnostics, i.e. comparing several appointments.
Contents
What the form records
The first four sections work through the segments of the CCFM, the next four the functions themselves. Section 9 collects complaints that occur more frequently when the basic functions are impaired.
The CCFM divides the head and neck region into four segments. Oro-vestibular refers to the front of the mouth with the lips, tongue, palate and rows of teeth, naso-pharyngeal to the area of the nose and nasopharynx. Added to these are the oropharynx with the soft palate, oro-pharyngeal, and the area around the hyoid bone and larynx, oro-hyoidal.
In the model, the segments are linked. That is why the form asks about signs in all four, even if someone comes because of a single complaint.
1 Oro-vestibular
Lips and lip closure, low-lying tongue, tooth impressions along the edge of the tongue, tongue coating, narrow high palate, crossbite, position of the lower jaw, malaligned teeth.
2 Naso-pharyngeal
Shape of the nasal tip and nostrils, nasal breathing and the AirFlip test for ventilation of the middle ear, also for each side separately.
3 Oro-pharyngeal
Breastfeeding, thick saliva, gag reflex, dry mouth, drooling at night, soft palate and uvula, short lingual frenulum, masseter and mentalis test.
4 Oro-hyoidal
Movement of the larynx during swallowing, double chin, asymmetry of the neck.
5 Breathing
Mouth breathing, noisy nasal breathing, mouth breathing even under light exertion, breathing with the shoulders and chest, nostrils drawing in, blocked nose.
6 Swallowing
No noticeable tension in the masticatory muscles, tensed chin muscle, head moving forward when swallowing.
7 Head balance
Head tilted backwards, to the side or towards the chest, stiff neck with forward head posture, pronounced cervical or lumbar lordosis, rounded back.
8 Articulation
Slurred pronunciation and incorrect formation of the S sound.
9 Complaints
14 groups, ranging from respiratory diseases, inflammation of the nose, sinuses and ears, snoring and sleep apnoea, through craniomandibular dysfunction (TMD), neck pain, back pain and headache, to tinnitus, dizziness, swallowing disorders, reflux and metabolic disorders.
of children with nasal obstruction had a lateral crossbite, compared with nasal breathers, analysed in 116 orthodontically treated children3
was the proportion with a disturbed anterior seal between lip and tongue in the same study3
That is why form findings such as crossbite, high palate or malaligned teeth appear on the same form as the functional signs. The study from Jerusalem is retrospective and says nothing about the sequence. In our view, these forms are, as a rule, the result of a function that has acted over years. You can find background on the tongue reference position and the swallowing pattern in the specialist articles.
Functional tests
The tests on the form
Some lines are based not on observation but on a short test. The form describes three of them in more detail.
Masseter test
The index and middle fingers rest on the angle of the lower jaw, and the person swallows. A short, clear contraction of both masticatory muscles is expected. If it is absent or uneven between the sides, the form treats this as an indication of oral dysfunction.
Mentalis test
You observe the chin during swallowing. In an orderly sequence, the chin muscle stays relaxed. If it tenses, the skin shows dimpling, the pincushion chin, or the tip of the chin pushes forward and the lower lip upwards.
AirFlip test
Mouth closed, nose held shut with two fingers. First press air against the closure, then try to breathe in against the closure. It is normal to feel the airflow into the middle ear and back, and the eardrum moving in both directions. Possible with and without the FaceFormer.
Nose, each side separately
You test nasal breathing for each side individually and repeat this at every appointment. A nose that is narrow on one side may be due to the nasal cycle, whose alternation during waking hours takes around two hours on average5.
The AirFlip is also available as an exercise; Module 11 describes it step by step. How the Eustachian tube ventilates the middle ear is explained in the article on ear pressure and pressure equalisation.
The masseter and mentalis tests only show the oral phase of swallowing; what happens behind the soft palate cannot be seen from the outside. If one side of the nose remains narrow over several appointments, the article on the deviated nasal septum can help you classify it.
In practice
How to use the form
The order partly determines how useful the findings are.
The most important rule is: observe first, then ask and test. You record lip closure, tongue and head balance in the habitual state, that is, as the person behaves when unobserved. Anyone who has once been asked to close their lips will no longer present an uninfluenced picture at that appointment.
breathed differently as soon as they knew their breathing was being recorded. Inhalation and exhalation times became longer, sighs and breathing pauses less frequent1
This has only been measured for breathing. For lip closure and head balance it is a plausible conclusion, because both can be corrected voluntarily as soon as someone pays attention to them.
- Step 1
Observe unnoticed
During the case history interview, look at the lips, airway, tongue and head balance without pointing this out.
- Step 2
Photos under the same conditions
Frontal in the habitual state, frontal with deliberate lip closure, plus a profile photo. Same distance, same lighting, same position.
- Step 3
Test specifically
Show the tongue, look at the oral cavity, nose on each side separately, masseter, mentalis and AirFlip test, a sip of water.
- Step 4
Tick and count
Enter the points for each section; add up sections 1 to 8 and section 9 separately.
- Step 5
Read the profile
Don’t just look at the total, but at where the points lie: in the mouth and nose, already in head balance, or mainly in the complaints.
- After four to six weeks
Repeat
Repeat the same procedure with the same photos and place the sections side by side.
The difference between the two frontal photos often says more than either one on its own. If lip closure is achieved effortlessly on request but is not used in everyday life, in our view this is purely a pattern problem. If it is only achieved with visible chin effort, clarify the airway first, because a blocked nose overlays the pattern.
Evaluation
Points, levels and what they mean
The interactive PDF does the calculation for you. On paper, you count the crosses.
The points from sections 1 to 8 add up to a total, which the form places in one of five levels. They range from a very low probability of a functional disorder at 1 to 2 points to a very high probability from 9 points. You count section 9 separately. If more than two symptom groups apply there, the form refers to a CCDS.
What the number does not do
- It does not measure how pronounced a disorder is.
- It does not diagnose a disease and does not rule one out.
- A change of a few points does not prove anything on its own.
What the number does
- It organises the baseline findings and makes them comparable.
- It shows in which sections signs cluster.
- It serves as a reminder for the next appointment and for the conversation with the person.
The level thresholds are based on clinical observation. The form has not yet been independently tested for reliability and validity, and CCFM and CCDS are working models, not diagnoses in an international classification. This could be tested. For a Brazilian assessment protocol with point scales in children, the agreement between two trained speech therapists was 0.992.
Progress
Documenting progress: intermediate steps before the symptom
Anyone who wants to assess training fairly looks first at the function that is meant to change, and only then at the complaint.
Was the training done as intended?
Frequency and execution belong in the documentation. Otherwise, a lack of effect cannot be interpreted.
Intermediate endpoints
First, the basic functions themselves: mouth closure, nasal breathing, swallowing pattern, head balance. In our view, they change before the symptom does.
Sufficient time frame
The exercise manual allows six to twelve months for a new pattern to run on its own. The assessment needs this much time too.
The person’s own reports
A dry mouth in the morning, nasal breathing at night and a calmer lip closure are often the first things described differently. They are also the least reliable reports.
Soft-tissue signs
Tongue coating, tooth indentations on the edge of the tongue and the chin sign during lip closure depend on the last few days and weeks.
The pattern itself
The tongue reference position on the palate and mouth closure in everyday life follow later.
Head balance
It changes the slowest, and small changes are hard to detect.
Structural findings
In adults, palate shape, bite and tooth position are baseline findings, not a measure of progress over weeks.
This sequence comes from our observation of progress. It has not been measured. For head balance, there is a measurement limit. For the craniovertebral angle, the smallest reliably detectable change was just under 5 degrees for the same examiner and 5.5 degrees for different examiners4. Unchanged head balance after a few weeks is therefore not evidence to the contrary. Compare profile photos, not your memory.
Such intermediate endpoints were recorded by the only randomised study on FaceFormer therapy to date, the Hamburg study with children. Lip strength, swallowing pattern and lip closure were assessed using a standardised form7. You can find the classification and limitations of all studies on the studies page.
Limits
When the triad is not the issue
The form describes a pattern that has developed slowly. It is not a tool for ruling out other conditions.
Neurological signs
Double vision, altered sensation in the face, one-sided weakness, a new speech disorder, a tongue that deviates to one side when stuck out. The sideways deviation is not a sign of an impaired basic function.
Signs of a space-occupying lesion
Persistent one-sided nasal obstruction, bloody nasal discharge, one-sided middle ear effusion in an adult without an infection, a palpable lump in the neck, unexplained weight loss.
Acute infections
Fever, severe one-sided sore throat with restricted mouth opening, acute ear pain, purulent discharge. Findings recorded during this time cannot be used.
Sudden and one-sided
A one-sided ear noise that starts overnight, hearing loss, one-sided facial or jaw pain with swelling.
In these cases, medical assessment takes priority. If pauses in breathing during sleep are observed, sleep medicine takes the lead and the training runs alongside it, as described in the article on snoring and sleep apnoea. In degenerative neuromuscular diseases such as ALS or advanced Parkinson’s, the training only begins after consultation with a doctor.
Conversely, if there is only a single sign, the model contributes little to the case. If several come together, such as craniomandibular dysfunction (TMD), neck pain and tinnitus, it is worth looking at the common starting point in breathing, swallowing and head balance.
Data protection
Patient data stays with you
The completed form contains health data. It is intended for your documentation, not for sending to us.
Do not send to us
Please do not send us completed forms, photos or findings with names. For questions about the form, an anonymised description is sufficient.
Only with consent
If you want to discuss a case with us, you need the explicit written consent of the person, or of the legal guardians in the case of children. Health data, including photos of findings, are specially protected under Art. 9 GDPR.
Record only what is necessary
The form has fields for contact details and ethnic origin. Only fill in what you need for treatment and documentation.
Store securely
Store completed PDFs as you would other treatment records, not in open cloud folders or in your email history.
The team will be happy to answer questions about using the form via the contact form, ideally without patient data.
Further training
Training, manual and practitioner directory
You can use the form without any training. Confidence in your findings comes from practising on real people.
The training courses and seminars with Dr. Klaus Berndsen and Sabine Berndsen cover functional analysis and diagnostics according to the CCFM, practical application and case studies. Participants practise the tests from the form on one another.
The manual on the methodology contains all diagnostic forms in print quality, together with the fundamentals of the method.
The practitioner directory lists certified practices, practitioners and coaches. There, people who do not want to train on their own can find support near them. You can apply for an entry online.
For an overview of the method, see the pages What is FaceFormer therapy? and Procedure and duration. How it fits alongside other approaches is explained under FaceFormer and other treatments.
Questions
Frequently asked
Where can I download the diagnostic form for FaceFormer therapy?
On this page, as an interactive PDF with automatic evaluation or as a print version. Both versions have the same content.
Who is the assessment form intended for?
For professionals who work with FaceFormer therapy or support it, for example in speech therapy, orthodontics, dentistry, physiotherapy and medicine. It is not designed for self-assessment at home, because several of the checks require a trained eye.
Does the form replace a medical diagnosis?
No. It is a screening of the basic functions of breathing, swallowing and head balance. It organises a functional assessment, but it does not establish or rule out any disease.
How often should I repeat the form?
An interval of four to six weeks has proven useful, each time with the same photos taken under the same conditions. In our view, soft-tissue signs such as tongue coating and tooth impressions change first, whereas structural findings in adults hardly change.
What does CCDS mean in the form?
Cranio-Cervical Dysfunction Syndrome. This is what Klaus and Sabine Berndsen call the combined occurrence of several typical complaints when the basic functions are impaired. It is a working model, not a diagnosis from an international classification.
May I send completed forms to FaceFormer?
Only with the express written consent of the person concerned and only if it is necessary for a query. For general questions about the form, an anonymised description is sufficient.
More articles from the knowledge section
Where to go next
Sources
- Han JN, Stegen K, Cauberghs M, Van de Woestijne KP (1997). Influence of awareness of the recording of breathing on respiratory pattern in healthy humans. European Respiratory Journal 10(1):161-166. PMID 9032510. Source
- Felício CM, Ferreira CL (2008). Protocol of orofacial myofunctional evaluation with scores. International Journal of Pediatric Otorhinolaryngology 72(3):367-375. PMID 18187209. Source
- Harari D, Redlich M, Miri S, Hamud T, Gross M (2010). The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. The Laryngoscope 120(10):2089-2093. PMID 20824738. Source
- Gallego-Izquierdo T, Arroba-Díaz E, García-Ascoz G, Val-Cano MDA, Pecos-Martin D, Cano-de-la-Cuerda R (2020). Psychometric Proprieties of a Mobile Application to Measure the Craniovertebral Angle: a Validation and Reliability Study. International Journal of Environmental Research and Public Health 17(18):6521. PMID 32911612. Source
- Kahana-Zweig R, Geva-Sagiv M, Weissbrod A, Secundo L, Soroker N, Sobel N (2016). Measuring and Characterizing the Human Nasal Cycle. PLoS One 11(10):e0162918. PMID 27711189. Source
- Berndsen K, Berndsen S (2023). FaceFormer-Therapie: Neurophysiologische Kausaltherapie bei Cranio-Cervikalem Dysfunktionssyndrom (CCDS) mit impliziten Symptomen von Schnarchen und Schlafapnoe. In: Langenhan J, Kopp S (eds.): Zahnärztliche Schlafmedizin. Thieme, Stuttgart, pp. 285-302. Source
- Korbmacher HM, Schwan M, Berndsen S, Bull J, Kahl-Nieke B (2004). Evaluation of a new concept of myofunctional therapy in children. International Journal of Orofacial Myology 30:39-52. PMID 15832861. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
