New Patient Form - Adult
Date of birth
Please upload photos of the front & back of your insurance card (if applicable).
Date of birth of primary card holder.
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
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
Eats too fast
Concerns with weight gain
Please add any specific details or comments regarding your eating habits.
Object sucking or chewing
Please add any specific details or comments regarding your habits.
Please add any specific details or comments regarding your dental history.
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)
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)
Speech harder to understand in long sentences
Mumbling or speaking softly
Trouble with saying some sounds
Previous Speech Therapy
Please add any specific details or comments regarding your speech.
Open mouth breathing
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)
Tell us a little about you!
Anything else we need to know?
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