Adult Intake Form
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Email Address
*
Mobile Number
*
Profession
Email Address
*
Home Address
Emergency Contact Person and Contact Number
Relationship to Patient
Health Professionals involved in your care: (e.g. Physician, Dentist, Orthodontist, etc) - Name and Address & Contact Number
How did you hear about us?
STATEMENT OF THE PROBLEM
Please share with us your concerns/ the reason you are seeking professional services.
When was this problem first noticed?
*
How has the problem changed/evolved?
*
What professional services have you received for this problem and when?
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Was there anything unusual about your mother’s pregnancy or birth with you?
Yes
No
If yes, please describe.
Were you full term?
Yes
No
If premature, by how many weeks?
Briefly describe how you were delivered:
Did you have any feeding/ swallowing problems as an infant/ toddler?
Yes
No
Please describe.
Please list any medications you take regularly:
Have you experienced any of the following:
Allergies
Sinus pain/issues
Frequent colds/flu
Ringing in the ears
Aching ears
Jaw/TMJ pain
Facial muscle pain
Snoring
Teeth clenching (daytime)
Difficulty swallowing pills
Gagging
Messy eating
Coughing/choking when eating
Need to burp after eating or drinking
Quick eating
Gulps
Hiccups
Stomachaches
Headaches
Grinding teeth (daytime)
Grinding teeth (asleep)
Drooling (day/sleep)
Leaning face/chin on palm/fist
Nail biting
Hair pulling
Chewing on end of pens/pencils
Lip licking
Gum chewing
Smoking/vaping
Opening packets/bottle caps with teeth
Teeth clenching (asleep)
Dry lips
Open mouth when walking
Eye pain
Upper respiratory infections
Pneumonia
Avoid certain food?
Back/leg aches
Neck pain
Feet/hands cold
Asthma
Sweating during sleep
Walking through the night to urinate
Frenectomy (tongue tie release)
Seizures
Loss of consciousness
GERD (acid reflux)
Visual difficulty
Heart problems
Hearing loss
Sleeping difficulties
Hearing loss
Tonsillectomy
Adenoidectomy
What position do you sleep?
Back
Left Side
Right Side
Stomach
Do you use any appliances while you sleep? (e.g. CPAP, oral splint, etc)
Yes
No
Have you have any surgeries? What type, age when surgery occurred, complications?
SLEEP AND BREATHING
Do you find yourself breathing through your nose or mouth during the day?
Yes
No
Do you find yourself breathing through your nose or mouth at night?
Yes
No
Do you snore?
Yes
No
Do you drool at night?
Yes
No
Do you wake up rested?
Yes
No
Do you wake up with a dry mouth?
Yes
No
DENTAL HISTORY
Did you use a pacifier?
Yes
No
If yes, until what age?
Did you suck your thumb/fingers?
Yes
No
If yes, until what age?
Were your baby teeth normal?
Yes
No
Were any baby teeth lost to accident or injury?
Yes
No
Do you have cavities or periodontal disease?
Yes
No
How often do you brush and floss?
Have your permanent teeth been chipped/injured/lost?
Yes
No
Which teeth and when?
Have you had any significant dental intervention (e.g. teeth removed, cavities filled etc) Describe:
Have you had orthodontic intervention or appliances before? Describe:
Do you use any orthodontic appliances now? Describe:
When will the appliance come off?
Did you wear braces and how long for? How long ago were they removed?
Do you wear a retainer?
Yes
No
Have you had treatment for feeding/swallowing issues or tongue thrust?
Yes
No
Has your occlusion (bite) become better, worse, or stayed the same in the last 6-12 months?
Other relevant information:
*
I give permission for Chatham Speech and Language to speak to professionals within my health care team for the purpose of sharing results of evaluations, discussing progress, and supporting me in any way.
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