New Patient Form

New Patient Form - Adult
Your name *

First Name Last Name
Date of birth *

Month Day Year
Date
Please upload photos of the front & back of your insurance card (if applicable).

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Cancel of
Date of birth of primary card holder.

Month Day Year
Date
Referred by *
Current concerns *
General doctor: *
Dentist: *
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
Feeding:

History of packing food in cheeks like a chipmunk History of spitting out food History of concerns with growth curve Sensory concerns with textures Slow eater (doesn’t finish meals) Grazes on food throughout the day Chokes or gags on food Won’t try new foods Noisy eating/chewing Pocketing Eats too fast Concerns with weight gain Picky eater
Please add any specific details or comments regarding your eating habits.
Habits:

Nail biting Cheek biting Lip biting Object sucking or chewing
Please add any specific details or comments regarding your habits.
Dental history:

Fillings Crowns Extractions Night guard TMJ concerns Orthodontics Orthodontic relapse
Please add any specific details or comments regarding your dental history.
Sleep issues:

Sleeps in strange positions Kicks and flails around at night Wakes easily or often Wakes up tired and not refreshed Grinds teeth while sleeping Sleeps with mouth open Gasps for air or stops breathing (sleep apnea) Heavy Breathing Noisy breathing Suspected sleep apnea Snores while sleeping Diagnosed with sleep apnea or UARS Sleep Study Completed
Please add any specific details or comments regarding your sleep.
Speech concerns or history:

Frustration with communication Difficult to understand by outsiders Difficulty speaking fast Difficulty getting words out (groping for words) Stuttering Speech harder to understand in long sentences Mumbling or speaking softly Trouble with saying some sounds Speech delay Previous Speech Therapy
Please add any specific details or comments regarding your speech.
Breathing issues:

Open mouth breathing Asthma Allergies Noisy/Audible breathing Frequent yawning/sighing Dry Chapped lips Halitosis (Bad breath)
Please add any specific details or comments regarding your 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) Hyperactivity/inattention Constipation
Tell us a little about you!
Anything else we need to know?
Email address *
Today's date *

Month Day Year
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New Patient Form - Adult