GROW: My Story
Complete Part 1 by filling in your child’s story and early development details across the fields.
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
PAGE 1 · When I was little…
Your name (parent/guardian)
*
First Name
Last Name
The Story of [blank]
*
Child's date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Before I was born, my mom had a [blank] pregnancy.
I was born [blank] weeks after I was conceived
and I arrived with a [blank] birth (see attached birth history sheet).
My mom decided to / not to nurse me.
to nurse me
not to nurse me
I nursed for [blank] months
and my mom says that I had an [blank] time with my feedings.
I was fed by a bottle for [blank] months
and started eating solid foods when I was [blank].
Someone told my parents that my tongue or lip was "tied"
Yes
No
and [blank] was done to help with it.
My parents say that being tongue tied runs in our family.
Yes
No
I loved sucking on my [blank] to comfort me
when I was [blank]
and was able to stop at age [blank].
My development was normal according to my doctors and parents.
Yes
No
I crawled with a
normal crawl
army crawl
rolled only
didn't crawl
I walked on my toes.
I walked on my toes.
My mom and pediatrician had concerns about my ability to [blank]
and cared enough about me to find help for me through [blank].
When I ate, I had challenges with [blank]
and my belly was [blank].
My parents described me as [blank]
and often had to [blank] to comfort me.
I had frequent ear infections.
Yes
No
I had a few boo-boos and scars that I would like you to know about
Yes
No
Boo-boos and scars
When I was littler I was sensitive to [blank]
and couldn't eat [blank].
I was scared of [blank]
because of [blank].
Tooth fairy [blank]
PAGE 2 · Now that I am bigger I…
…am a [blank] learner
…am [blank] around new people
…am sensitive to [blank]
…sometimes gag when I [blank]
…usually breathe through my
mouth
nose
both
Breathing notes
…love to play [blank] (sports, games, instruments, etc.)
…have a body that is strong, coordinated and balanced (0–4)
0
1
2
3
4
PAGE 3 · When I am sleeping, my family says that I…
When I am sleeping, my family says that I…
snore
wet the bed
walk in my sleep
have night terrors and bad dreams that make me scream in my sleep
suck on my [blank]
grind my teeth
wake up frequently during the night
need [blank] to be on to go to sleep (TV, music, fan, etc.)
have my mouth open most of the time
suck on my [blank]
need [blank] to be on to go to sleep (TV, music, fan, etc.)
PAGE 4 · When I am awake…
…I usually feel [blank]
…I often need [blank]
…I swallow by
sticking my tongue out
squishing my lips and cheeks
When I am awake…
I have a hard time licking ice cream cones
I have a hard time puckering, kissing or whistling
I cannot swallow pills
I sometimes choke on my food
I gag easily
I am a picky eater
I have difficulty concentrating
I learn differently than most of my friends
I have headaches or jaw pain
I wear glasses to see better
Sometimes I have a hard time hearing people talk to me
I talk with a lisp
I have scars on [blank]
I have broken bones [blank]
I have been told that I have flat feet
I have had more than a few cavities
I have already had a dentist help me get straighter teeth [blank]
I have scars on [blank]
I have broken bones [blank]
I have already had a dentist help me get straighter teeth [blank]
I lost my first teeth at [blank]
PAGE 5 · My parents want me to:
My parents want me to:
Have straighter teeth and a beautiful smile
Breathe better
Sleep better
Have a tongue that works better through tongue evaluations and exercises
Be able to chew and swallow better
Have my [blank] feel or work better
Have gentle dental care made just for me that supports how my face grows and how my body and brain work together
Have FUN during my GROW and PLAYtime while my face, body and brain learn to work together
Promise to take care of my teeth, my dental appliances and do my GROW & PLAYtime exercises to make sure that my treatment is as effective as possible
Become the best that I can be!
Have my [blank] feel or work better
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