Toothpillow - Online Screening (Beta 5)

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You will need these 6 photos to complete your child's assessment. Pause now and take these photos and then come back and continue.When you have them saved on your device, click next
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Who's the person we can thank for referring you?* This field is required.Please provide a specific name so that we can appropriately attribute credit to the individual who referred/shared with you.
3
Where do you live?* This field is required.(Currently ONLY accepting patients in the US)
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
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State
Zip / Post Code
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Afghanistan
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Angola
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Antigua and Barbuda
Argentina
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Australia
Austria
Azerbaijan
The Bahamas
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Belgium
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Benin
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Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
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Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
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The Gambia
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Germany
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Guam
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Guyana
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Hong Kong
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India
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Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
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Kiribati
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Norway
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Paraguay
Peru
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Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Samoa
San Marino
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Saudi Arabia
Senegal
Serbia
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Singapore
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eSwatini
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Other
Country
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Patient's Name* This field is required.
First Name
Last Name
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Patient's Age* This field is required.(Only accepting patients between the ages of 3-12)
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Patient's Birthday* This field is required.
Date
Month
Day
Year
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Patient Biological Gender
Male
Female
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Parent/Guardian Name* This field is required.
First Name
Last Name
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Parent/Guardian Email* This field is required.
example@example.com
10
Phone Number* This field is required.
Area Code
Phone Number
11
Text Messaging Opt-in* This field is required.We will primarily communicate with you via our secure Toothpillow smartphone app, but from time to time may use Text messaging which may not be fully secure. To consent, reply YES.
YESNO
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What concerns do you have with your child's dental health?
Crooked teeth
Jaw development
Mouth breathing habits
Sucking habits
Other
13
Sleep and Breathing Questionnaire* This field is required.Please indicate if your child experiences or has experienced any of these symptoms below by using this scale to measure the severity of these symptoms.
Never
Rarely
Often
Always
Unknown
Snoring
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Labored, difficult or loud breathing at night
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Gasping for air while sleeping
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Mouth breathes while sleeping
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Mouth breathes during day
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Restless sleep
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Grinds teeth while sleeping
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Talks in sleep
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Excessive sweating while sleeping
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Wakes up at night
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Wets the bed (currently)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
History of bed wetting
Row 11, Column 0
Row 11, Column 1
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Row 11, Column 3
Row 11, Column 4
Sleepy and/or irritable during the day
Row 12, Column 0
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Row 12, Column 3
Row 12, Column 4
Headaches
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Frequent throat infections
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Row 14, Column 4
Seasonal allergies
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Row 15, Column 4
Ear infections or history of ear infections
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Difficulty listening/ often interrupts
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Hyperactive
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
ADD/ADHD
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Sensory Issues
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Row 20, Column 4
Speech Issues
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Row 21, Column 4
Avoidance towards food or certain types of food
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Row 22, Column 4
Snoring
Labored, difficult or loud breathing at night
Gasping for air while sleeping
Mouth breathes while sleeping
Mouth breathes during day
Restless sleep
Grinds teeth while sleeping
Talks in sleep
Excessive sweating while sleeping
Wakes up at night
Wets the bed (currently)
History of bed wetting
Sleepy and/or irritable during the day
Headaches
Frequent throat infections
Seasonal allergies
Ear infections or history of ear infections
Difficulty listening/ often interrupts
Hyperactive
ADD/ADHD
Sensory Issues
Speech Issues
Avoidance towards food or certain types of food
Never
Row 0, Column 0
Rarely
Row 0, Column 1
Often
Row 0, Column 2
Always
Row 0, Column 3
Unknown
Row 0, Column 4
Never
Row 1, Column 0
Rarely
Row 1, Column 1
Often
Row 1, Column 2
Always
Row 1, Column 3
Unknown
Row 1, Column 4
Never
Row 2, Column 0
Rarely
Row 2, Column 1
Often
Row 2, Column 2
Always
Row 2, Column 3
Unknown
Row 2, Column 4
Never
Row 3, Column 0
Rarely
Row 3, Column 1
Often
Row 3, Column 2
Always
Row 3, Column 3
Unknown
Row 3, Column 4
Never
Row 4, Column 0
Rarely
Row 4, Column 1
Often
Row 4, Column 2
Always
Row 4, Column 3
Unknown
Row 4, Column 4
Never
Row 5, Column 0
Rarely
Row 5, Column 1
Often
Row 5, Column 2
Always
Row 5, Column 3
Unknown
Row 5, Column 4
Never
Row 6, Column 0
Rarely
Row 6, Column 1
Often
Row 6, Column 2
Always
Row 6, Column 3
Unknown
Row 6, Column 4
Never
Row 7, Column 0
Rarely
Row 7, Column 1
Often
Row 7, Column 2
Always
Row 7, Column 3
Unknown
Row 7, Column 4
Never
Row 8, Column 0
Rarely
Row 8, Column 1
Often
Row 8, Column 2
Always
Row 8, Column 3
Unknown
Row 8, Column 4
Never
Row 9, Column 0
Rarely
Row 9, Column 1
Often
Row 9, Column 2
Always
Row 9, Column 3
Unknown
Row 9, Column 4
Never
Row 10, Column 0
Rarely
Row 10, Column 1
Often
Row 10, Column 2
Always
Row 10, Column 3
Unknown
Row 10, Column 4
Never
Row 11, Column 0
Rarely
Row 11, Column 1
Often
Row 11, Column 2
Always
Row 11, Column 3
Unknown
Row 11, Column 4
Never
Row 12, Column 0
Rarely
Row 12, Column 1
Often
Row 12, Column 2
Always
Row 12, Column 3
Unknown
Row 12, Column 4
Never
Row 13, Column 0
Rarely
Row 13, Column 1
Often
Row 13, Column 2
Always
Row 13, Column 3
Unknown
Row 13, Column 4
Never
Row 14, Column 0
Rarely
Row 14, Column 1
Often
Row 14, Column 2
Always
Row 14, Column 3
Unknown
Row 14, Column 4
Never
Row 15, Column 0
Rarely
Row 15, Column 1
Often
Row 15, Column 2
Always
Row 15, Column 3
Unknown
Row 15, Column 4
Never
Row 16, Column 0
Rarely
Row 16, Column 1
Often
Row 16, Column 2
Always
Row 16, Column 3
Unknown
Row 16, Column 4
Never
Row 17, Column 0
Rarely
Row 17, Column 1
Often
Row 17, Column 2
Always
Row 17, Column 3
Unknown
Row 17, Column 4
Never
Row 18, Column 0
Rarely
Row 18, Column 1
Often
Row 18, Column 2
Always
Row 18, Column 3
Unknown
Row 18, Column 4
Never
Row 19, Column 0
Rarely
Row 19, Column 1
Often
Row 19, Column 2
Always
Row 19, Column 3
Unknown
Row 19, Column 4
Never
Row 20, Column 0
Rarely
Row 20, Column 1
Often
Row 20, Column 2
Always
Row 20, Column 3
Unknown
Row 20, Column 4
Never
Row 21, Column 0
Rarely
Row 21, Column 1
Often
Row 21, Column 2
Always
Row 21, Column 3
Unknown
Row 21, Column 4
Never
Row 22, Column 0
Rarely
Row 22, Column 1
Often
Row 22, Column 2
Always
Row 22, Column 3
Unknown
Row 22, Column 4
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Any history of:
Tonsils/Adenoids removal
Tooth extraction
Cavities
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Habits:
Thumb/finger sucking
Pacifier
Bottle
Other
16
What do you ideally want for your child?
Improved overall health
Straight teeth and well-developed jaws
Potentially avoid braces
Other
17
How much do you know about Toothpillow?
Not much
I was referred by a dentist
I have basic understanding and reviewed the website
I have done a lot of research
18
Is there anything specific you want explained?
The cause of crooked teeth
The risks and limitations of braces
How Toothpillow works
How treatment can potentially improve my childs overall health.
19
Is your child taking any medications?If yes, please list all medicatons.
20
When was you child's last dental exam?
WIthin the last 6 months
6-12 months ago
Longer than a year ago
They have never seen a dentist
21
Who is your regular general dentist and name of their office?
22
Questions or Concerns you'd like the Doctor to know about
23
Front Facing(click Next > to upload)
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Front Facing Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
25
Right Side Profile(click Next > to upload)
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Side Profile Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
27
Bite Down - All the TeethIt's important for our doctors to get a good view of your child's natural bite. So please have them pretend they're taking a bite of an apple and pause so that you can snap that photo.
28
Teeth Only Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
29
The Upper Arch
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Upper Arch Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
31
The Lower Arch(click Next > to upload)
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Lower Arch Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
33
Tongue to Roof Photo(click Next > to upload)
34
Tongue to Roof Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
35
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ORDER SUMMARY
Total costUSD
Optional: Recorded Video Evaluation from your Treating DoctorYou will receive a 5-10 min recorded video from the treating doctor reviewing your submission and discussing the specific points of concern. (Note: If you choose to move forward with a Toothpillow treatment this payment will be credited to your cost)
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Review by Toothpillow's Clinical Advisory BoardThis step is to determine if your child is a candidate for treatment and if virtual care is appropriate or if an in-office exam is needed.
$FreeEdit
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Total cost $0.00
36
Informed Consent* This field is required.
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