2022 Adult Assessment Sheet (East Bay)

Adult Assessment Form
Patient's Name

First Name Last Name
Birthdate

Month Day Year
Date
Age
Medical Issues
Medications Taking:
Allergies
Previous Clip or Release of Tongue? (Date)
Email
example@example.com
Bet Phone Number to Reach You
Please enter a valid phone number.
Best Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent 2 Name

First Name Last Name
Parent 2 DOB

Month Day Year
Date
Parent 2 Email
example@example.com
Parent 2 Best Phone
Please enter a valid phone number.
Have you experienced any of the following issues?

Please check or elaborate as needed.
Speech

Frustration with communication Difficult to understand by parents Difficult to understand by outsiders % of time others misunderstand you Difficulty speaking fast Difficulty getting words out (groping for words) Trouble with sounds Speech delay Stuttering Speech harder to understand in long sentences Speech therapy
Which Sounds are you having trouble with?
When was your speech delay?
How long have you had speech therapy?
Feeding

Frustration when eating Difficulty transitioning to solid foods Slow eater (doesn’t finish meals) Small appetite/Trouble gaining weight Grazes on food throughout the day Packing food in cheeks like a chipmunk Picky eater/with textures Choking or gagging on food Spits out food Won’t try new foods Other
Picky with What Foods or Textures?
Nursing or Bottle-Feeding Issues as a Baby

Painful nursing or shallow latch Poor weight gain Reflux or spitting up Gassy (tooted a lot) as baby Milk leaked out of mouth/messy eater Poor milk supply Nipple shield needed for nursing Clicking or smacking noise when eating Cried a lot/colic as baby Other
Sleep Issues

Sleeps in strange positions Sleeps restlessly (moves a lot) Wakes easily or often Wets the bed Wakes up tired and not refreshed Grinds teeth while sleeping Sleeps with mouth open Snores while sleeping Gasps for air or stops breathing (sleep apnea)
How often do you Snore while Sleeping?
Other Related Issues

Neck or shoulder pain or tension TMJ Pain, clicking, or popping Headaches or migraines Strong gag reflex Prolonged thumb sucking/pacifier use Mouth open /mouth breathing during the day Tonsils or adenoids removed previously Ear tubes previously/lots of ear infections Reflux (medicated or not) Hyperactivity/Inattention Constipation
Lip-Tie Issues

Difficult or tender to brush top teeth Top teeth don’t show when smiling Gap between two front teeth Cavities on front teeth Trouble eating from a spoon/flips spoon over Trouble with B,P,M or W sounds
Any Other Concerns?
Physician
Therapist
Who referred you to us?
Insurance Information
Do you have dental insurance coverage?

Yes No
Dental Insurance Company
Insurance Phone
Insurance ID Number/SSN
Group or Policy Number
Your Date of Birth

Month Day Year
Date
FINANCIAL POLICIES

Arrangement and Conditions
Welcome to East Bay Tongue Tie Center. We are pleased that you have selected our office for you or your child’s care and we value the confidence you have expressed in choosing us. We understand that parents are concerned not only with the quality of their children’s care, but also with the costs of professional services. Therefore, we have outlined below the financial policies of this office.

• Payment is expected the day service is rendered. This includes co-payments and deductibles.

• If you carry dental insurance, please present your current insurance card the day of your child’s appointment.

• Delinquent accounts may be subject to a monthly finance charge.

• Your account is subject to a $50.00 charge for no shows or cancellations without a 24 hour notification.

• Please remember, once an appointment has been made this time as been reserved especially for your child.

• Please make sure that the new patient paperwork is filled out and submitted 24 hours prior to the appointment as this will be a confirmation of your appointment.

• There will be $25.00 fee for returned checks due to insufficient funds.
I certify that my child is covered under (please type insurance below) insurance and I assign appropriate insurance benefits directly to East Bay Tongue Tie Center. *

Yes
Insurance Type
I understand that I am responsible for any remaining balance not covered by my insurance, and hereby authorize East Bay Tongue Tie Center to release all information necessary to secure payment for dental services rendered. I authorize the use of this signature on all my insurance submissions whether electronic or manual.

The parent/guardian, signed below agrees to be fully responsible for the total payments of procedures per- formed in this office. In cases of shared custody and/or divorced/separated parents, the parent/guardian pre- senting the child for treatment is responsible for the charges incurred.

I have read and fully understand the financial policy of this office and have received a copy.
Parent/Guardian Signature *

Clear
Today's Date

Month Day Year
Date
Type name of Signature Above
MEDICAL INFORMATION RELEASE FORM

(HIPAA Release Form)
Name
Date of Birth

Month Day Year
Date
I hereby authorize Dr. Bill Arnold and affiliates, employees, or agents to release any personal health information (e.g., information relating to the diagnosis, records, treatment, claims payment, and healthcare services) *

Yes
Parent/Spouse/Relative
Referring Provider
Pediatrician
Lactation Consultant
Bodyworker/Doula/Midwife/Other
SLP/OT/PT/Myofunctional therapist
I do NOT authorize Dr. Bill Arnold or affiliates to release any medical information *This Release of Information will remain in effect until terminated by me in writing. *

I do NOT Authorize
Please call me for messages at:

Home Work Cell
Phone Number of Checked Box Above:

Area Code Phone Number
If unable to reach me:

You may leave a detailed message Please leave me a message asking me to return your call Other
Signature

Clear
Should be Empty:

Adult Assessment Form

Have you experienced any of the following issues?

Insurance Information

FINANCIAL POLICIES

MEDICAL INFORMATION RELEASE FORM