GROW Clinical Screening Intake
Complete this intake form for your child before the visit.
About your child
Many things can wait. Children cannot. Today their bones are being formed, their blood is being made, their senses are being developed. To them we cannot say "tomorrow." Their name is today. – Gabriela Mistral
Child's name
*
First Name
Middle Name
Last Name
Child's date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your name (parent/guardian)
*
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for appt.
Referred by
History of snoring/OSA
Yes
No
In the past
Occasionally
Swallowing issues
Yes
No
In the past
Occasionally
Speech issues
Yes
No
In the past
Occasionally
Poor sleep quality
Yes
No
In the past
Occasionally
Neuro, systemic and medications
Headaches
*
Yes
No
In the past
Occasionally
Learning disorder
Yes
No
In the past
Other
Please describe
Movement disorder
Yes
No
In the past
Other
Please describe
Significant adverse childhood events (ACE)
Yes
No
Other
Please describe
Bedwetting/potty training issues?
Yes
No
In the past
Other
Please describe
Is child being seen by PT/OT/SPT?
Yes
No
If so, for how long?
Systemic
Food sensitivities
Allergies
Picky eater
Digestive challenges
Other conditions
Please describe
Medications and supplements
Office use only
Staff entry
Crowded teeth
Upper
Lower
Spaces between teeth
Upper
Lower
Crossbite
Right
Left
Anterior
Broken/decayed – Upper
Broken/decayed – Lower
Missing – Upper
Missing – Lower
Developmental stage
Please Select
Early
Primary
Mixed
Permanent
Restrictive lingual frenum
Please Select
Structural
Functional
Tender floor of mouth – Right (0–3)
Tender floor of mouth – Left (0–3)
Restrictive labial frenulae
Upper
Lower
Restrictive buccal frenulae
Upper
Lower
Tongue posturing
Jaw tracking
Tender buccinator fascia (0–3)
Compromise of nasal patency
Right
Left
Tonsil grade – Right (0–3)
Tonsil grade – Left (0–3)
Mallampati (0–4)
Skeletal
Underbite (Class 3)
Overbite (Class 2)
Deep bite
Posterior crossbite functional or skeletal
Forward head posture
Shoulder rolling/slouching
Facial asymmetry
High palate
Submit
Should be Empty: