2022 Adult Assessment Sheet (East Bay)

Adult Assessment Form
Patient's Name

First NameLast Name
Birthdate

MonthDayYear
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

CityState / Province

Postal / Zip Code
Parent 2 Name

First NameLast Name
Parent 2 DOB

MonthDayYear
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 communicationDifficult to understand by parentsDifficult to understand by outsiders% of time others misunderstand youDifficulty speaking fastDifficulty getting words out (groping for words)Trouble with soundsSpeech delayStutteringSpeech harder to understand in long sentencesSpeech therapy
Which Sounds are you having trouble with?
When was your speech delay?
How long have you had speech therapy?
Feeding

Frustration when eatingDifficulty transitioning to solid foodsSlow eater (doesn’t finish meals)Small appetite/Trouble gaining weightGrazes on food throughout the dayPacking food in cheeks like a chipmunkPicky eater/with texturesChoking or gagging on foodSpits out foodWon’t try new foodsOther
Picky with What Foods or Textures?
Nursing or Bottle-Feeding Issues as a Baby

Painful nursing or shallow latchPoor weight gainReflux or spitting upGassy (tooted a lot) as babyMilk leaked out of mouth/messy eaterPoor milk supplyNipple shield needed for nursingClicking or smacking noise when eatingCried a lot/colic as babyOther
Sleep Issues

Sleeps in strange positionsSleeps restlessly (moves a lot)Wakes easily or oftenWets the bedWakes up tired and not refreshedGrinds teeth while sleepingSleeps with mouth openSnores while sleepingGasps for air or stops breathing (sleep apnea)
How often do you Snore while Sleeping?
Other Related Issues

Neck or shoulder pain or tensionTMJ Pain, clicking, or poppingHeadaches or migrainesStrong gag reflexProlonged thumb sucking/pacifier useMouth open /mouth breathing during the dayTonsils or adenoids removed previouslyEar tubes previously/lots of ear infectionsReflux (medicated or not)Hyperactivity/InattentionConstipation
Lip-Tie Issues

Difficult or tender to brush top teethTop teeth don’t show when smilingGap between two front teethCavities on front teethTrouble eating from a spoon/flips spoon overTrouble with B,P,M or W sounds
Any Other Concerns?
Physician
Therapist
Who referred you to us?
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, we will provide you with a superbill for you to submit to your insurance for reimbursement.

• We will also provide you with the medical diagnostic and treatment codes so you can submit your superbill to your medical insurance as well if you would like.

• We appreciate if you are not going to show up to your appointment, please let us know as there are other families wanting appointments and slots are limited. If you no show or cancel within 48 hours, you will need to make a deposit of $100 if you would like to reschedule which will go towards your consult fee of $250.

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

• Please make sure that the new patient paperwork is filled out and submitted 48 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 understand that I am responsible for all fees associated with my appointment. A superbill will be provided to me if I would like to submit to my insurance.

The parent/guardian, signed below agrees to be fully responsible for the total payments of procedures performed in this office. In cases of shared custody and/or divorced/separated parents, the parent/guardian presenting 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

MonthDayYear
Date
Type name of Signature Above
MEDICAL INFORMATION RELEASE FORM

(HIPAA Release Form)
Name
Date of Birth

MonthDayYear
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
Please call me for messages at:

HomeWorkCell
Phone Number of Checked Box Above:

Area CodePhone Number
If unable to reach me:

You may leave a detailed messagePlease leave me a message asking me to return your callOther
Signature

Clear
Should be Empty:

Adult Assessment Form

Have you experienced any of the following issues?

FINANCIAL POLICIES

MEDICAL INFORMATION RELEASE FORM