PDOH: New Patient Frenectomy Forms
New Patient Registration
Child's Name
First Name
Middle Name
Last Name
Preferred Name:
*
Birthdate:
*
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Month
-
Day
Year
Date
Gender:
*
Age:
*
Parent's Name:
*
Birthdate:
*
-
Month
-
Day
Year
Date
Cell Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Primary Dental Insurance Co.
*
Policy Holder Name:
*
Policy Holder Employer
*
Date of Birth of Insured:
*
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Month
-
Day
Year
Date
Group #
*
SSN of Insured
*
Pediatrician:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Lactation Consultant:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who may we thank for referring you?
*
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Medical History
Medical Problems (If Yes, please describe)
*
None
Yes
Heart Disease or Problems (if Yes, please describe)
*
None
Yes
Bleeding Disorders (If Yes, please describe)
*
None
Yes
Allergies to foods or medications (If Yes, please describe)
*
None
Yes
Any condition not listed above:
Past surgeries:
Weeks at Birth (gestation)
*
Birth Weight
*
Current Weight
*
Birth Hospital
*
Infants are usually given Vitamin K at birth to prevent bleeding in the first 8 weeks of life. Did your child receive the Vitamin K shot?
*
Yes
No
Was your child's birth...
*
Vaginal birth
C-Section Birth
Any birth complications?
*
Are you currently breastfeeding?
*
Yes
No
Breastfeeding pain on a scale of 1-10:
*
ONLY FILL OUT THIS SECTION IF YOUR CHILD IS < 1
1. Has your child experienced any of the following symptoms? Please elaborate as needed.
unable to latch properly
slides of nipple
falls asleep while eating
gumming/chewing on the nipple
clicking sounds when nursing/feeding
milk leaking from mouth while feeding
wiggles/pulls away when feeding
favors one side (left or right)
colic symptoms
reflux symptoms/spits up often
gas
gagging/choking/coughing when eating
poor weight gain
hiccups often
lip curls under when nursing or taking bottle
open mouth breathing
congestion
loud breathing sounds (snores/snorts)
prefers one side over the other (right or left)
Elaborate here, if needed:
2. Do you have any of the following symptoms? Please elaborate as needed.
severe pain when latching
severe pain once latched and nursing
creased/flattened nipples
lipstick shaped nipples
cracked/bleeding/blistered nipples
poor or incomplete breast draining
plugged/clogged ducts
using nipple shield
nipple or breast infections (thrush, mastitis)
Elaborate here, if needed:
To the best of my knowledge, I certify that the above information is complete and correct. I understand it is my responsibility to inform this office of any changes in my child’s medical status or any other information provided in this form.
Parent's Signature
*
Date:
*
-
Month
-
Day
Year
Date
ONLY FILL OUT THIS SECTION IF YOUR CHILD IS OLDER THAN 18 MONTHS
Speech and Sleep Questionnaire
Patient's Name
First Name
Middle Name
Last Name
Today's Date:
-
Month
-
Day
Year
Date
Has your child experienced any of the following issues? Check or elaborate as needed.
1. Speech
Frustration with communication
Difficulty to understand by parents
Difficulty to understand by outsiders
% of time you understand your child
Difficulty speaking fast
Difficulty getting words out
Trouble with sounds (which?)
Speech delay (when?)
Stuttering
Speech harder to understand in long sentences
Speech therapy (how long?)
Mumbling or speaking softly
“Baby talk”
Elaborate here, if needed:
2. Feeding
Frustration when eating
Difficulty transitioning to solid foods
Slow eater (doesn’t finish meals)
Grazes on food throughout the day
Packing food in cheeks
Picky eater / with textures (which?)
Choking or gagging on food
Spits out food
Won’t try new foods
Other
Elaborate here, if needed:
3. Nursing or Bottle Feeding Issues as a Baby
Painful nursing or shallow latch
Poor weight gain
Reflux or spitting up
Unable to hold pacifier
Milk dribbling out of mouth
Poor supply
Nipple shield required for nursing
Clicking or smacking noise when eating
Other
Elaborate here, if needed:
4. Sleep Issues
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
Snores while sleeping (how often?)
Gasps for air or stops breathing (sleep apnea)
Elaborate here, if needed:
5. Other Related Issues
Neck or shoulder pain or tension
TMJ pain, clicking or popping
Headaches or migraines
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
Elaborate here, if needed:
Anything else we need to know:
Pediatrician:
Who referred you to us?
Speech Therapist:
Parent's Signature
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