Toothpillow - Online Screening (Beta 4)

1
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.
2
Where do you live?* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
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California
Colorado
Connecticut
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District of Columbia
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Maine
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Michigan
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Ohio
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Rhode Island
South Carolina
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Tennessee
Texas
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Vermont
Virginia
Washington
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State
Zip Code
Please Select
Please Select
United States
Afghanistan
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Algeria
American Samoa
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Angola
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Argentina
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Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
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Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
Ecuador
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Eritrea
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Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
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The Gambia
Georgia
Germany
Ghana
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India
Indonesia
Iran
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Ireland
Israel
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Jamaica
Japan
Jersey
Jordan
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Kiribati
North Korea
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Lithuania
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Malawi
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Morocco
Mozambique
Myanmar
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Namibia
Nauru
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New Zealand
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Portugal
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Russia
Rwanda
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Samoa
San Marino
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Senegal
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eSwatini
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Yemen
Zambia
Zimbabwe
Other
Country
3
Patient's Name* This field is required.
First Name
Last Name
4
Patient's Age* This field is required.
5
Patient's Birthday* This field is required.
Date
Month
Day
Year
6
Patient Biological Gender
Male
Female
7
Parent/Guardian Name* This field is required.
First Name
Last Name
8
Parent/Guardian Email* This field is required.
example@example.com
9
Phone Number* This field is required.
Area Code
Phone Number
10
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
11
What concerns do you have with your child's dental health?
Crooked teeth
Jaw development
Mouth breathing habits
Sucking habits
Other
12
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
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Sleepy and/or irritable during the day
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
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:
Adnoid/tonsil removal
Tooth extraction
Cavities
14
Habits:
Thumb/finger sucking
Pacifier
Bottle
Other
15
What do you ideally want for your child?
Improved overall health
Straight teeth and well-developed jaws
Potentially avoid braces
Other
16
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
17
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.
18
Is your child taking any medications?If yes, please list all medicatons.
19
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
20
Who is your regular general dentist and name of their office?
21
Questions or Concerns you'd like the Doctor to know about
22
Front Facing(click Next > to upload)
23
Front Facing Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
24
Side Profile(click Next > to upload)
25
Side Profile Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
26
Bite Down - All the Teeth(click Next > to upload)
27
Teeth Only Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
The Upper Arch(click Next > to upload)
29
Upper Arch Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
The Lower Arch(click Next > to upload)
31
Lower Arch Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
Tongue to Roof Photo(click Next > to upload)
33
Tongue to Roof Photo Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
34
Toothpillow Assessment Details and Options
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My Bag
2
My Bag
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$20
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Size:Small
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Quantity:1
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Size:Small
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ORDER SUMMARY
Total costUSD
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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Evaluation by your state-licensed Treating ProviderYour local Toothpillow Treating Provider will review your submission and complete a diagnostic evaluation by reviewing your symptoms and photos.
$FreeEdit
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Optional: Personalized Video Consult 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)
$25.00Edit
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Total cost $0.00
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Informed Consent* This field is required.
Should be Empty: