clarkstondental.com-Intake Form

Name:
Birthdate:

MonthDayYear
Date
Phone:
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Referred by:
Date

MonthDayYear
Date
Orthodontic / Airway Assessment

Early intervention for children's oral and facial developmentPediatric clenching/grindingRestricted maxilla/high palateOverjet (Class II malocclusion)Overbite (Deep bite)Underbite (Class III malocclusion)Craniofacial / midface deficiencyADD / ADHD / focus problemsInsomniaNighttime enuresis (Bed wetting)Night terrors / nightmaresAnxiety / DepressionEnlarged tonsilsSnoringOther
Myofunctional Evaluation

Open mouth posture/mouth breathingTongue thrustDysphagia (trouble swallowing)Excessive gag reflexLip/Tongue tieVenous pooling under eyes (allergic shiners)Low rest tongue postureSpeech concernsHabits (finger, thumb, blanket sucking)Habits (nail, lip biting)Previous Myofunctional TherapyCurrent Myofunctional Therapy
Previous Lip/Tongue Tie Date:
Myofunctional Therapist Name
Sleep Breathing Disorders/Evaluate for oral sleep appliance

Mild sleep apneaModerate sleep apneaSevere sleep apneaUARS (upper airway resistance syndrome)Home sleep screening —AdultSleep/Breathing disorders-Child
Any other provider involved in this patient’s care Name
Emergency exam

Broken teethAbscess / Infection
Other:
*As a courtesy we ask that you kindly let your patient that we ask for a 48 hours notice to reschedule or cancel appointments.

Please advise the patient that there is a $150 consultation fee due at the time of scheduling.*
Copy of CBCT with radiology report

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Any recent radiographs

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Other:

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