New Patient Form - Child
Patient's date of birth
Please upload photos of the front & back of insurance card (if applicable).
Date of birth of primary card holder.
Pass newborn hearing screening?
Please list the name and phone for any other medical professionals including, but not limited to the following: Orthodontist, Allergist, ENT, Occupational Therapy, Physical Therapy, Speech Pathologist, Chiropractor, Craniosacral Therapist
Frustration when eating
Difficulty transitioning to solid foods
Slow eater (doesn’t finish meals)
Grazes on food throughout the day
Packs food in cheeks like a chipmunk
Choking or gagging on food
Spits out food
Won’t try new foods
Eats too fast
Concerns with growth curve
Concerns with weight gain
Sensory concerns with textures
Please add any specific details or comments regarding your child's feeding history.
Object sucking or chewing
Please add any specific details or comments regarding your child's habits.
Please add any specific details or comments regarding your child's dental history.
Sleeps in strange positions
Kicks and flails around at night
Wakes easily or often
Wets the bed
Wakes up tired and not refreshed
Grinds teeth while sleeping
Sleeps with mouth open
Gasps for air or stops breathing (sleep apnea)
Suspected sleep apnea
Snores while sleeping
Diagnosed with sleep apnea or UARS
Sleep Study Completed
Please add any specific details or comments regarding your child's sleeping.
Frustration with communication
Difficult to understand by parents
Difficult to understand by outsiders
Difficulty speaking fast
Difficulty getting words out (groping for words)
Speech harder to understand in long sentences
Mumbling or speaking softly
Do you understand your child when other less familiar people do not?
Trouble with saying some sounds
Previous Speech Therapy
Please add any specific details or comments regarding your child's speech.
Open mouth breathing
Dry Chapped lips
Halitosis (Bad breath)
Please add any specific details or comments regarding your child's breathing.
Other related issues:
Neck or shoulder pain/tension
TMJ pain, clicking or popping
Headaches or migraine
Strong gag reflex
Mouth open/mouth breathing during the day
Tonsils or adenoids removed previously
Ear tubes previously
Reflux (medicated or not)
What is your child's favorite TV show?
What is your child's favorite food?
What is your child's favorite outside activity?
Does your family have a pet? If so, what kind(s)?
Do you (the caregiver) read books or listen to podcasts?
What languages do you (the caregiver) speak?
Tell us a little about your family!
Anything else we need to know?
Relation to patient
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