Parent / Guardian Full Name
*
Child's Full Name
*
Email
*
Phone
*
Current Patient?
*
Yes
No
Do you have any sleep concerns for your child?
*
Yes
No
Has your child had a sleep study?
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Yes
No
Does your child:
wake up refreshed
get the appropriate amount of sleep at night
tend to be sleepy during the day
tend to be hyperactive
struggle with concentration
have a hard time in school
While sleeping, does your child:
stop breathing
snore
breathe with mouth open
grind
toss and turn
tilt head back
have trouble waking up
have disheveled bedding
wet the bed
sleep talk
sleep walk
have nightmares or night terrors
perspire excessively
wake up with headaches
wake up frequently
wake up with dark circles under eyes
sleep in unusual positions
Has your child been diagnosed with a lip or tongue tie?
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Yes
No
Has your child:
had a lip tie release (frenectomy)
had a tongue tie release (frenectomy)
had adenoids removed
had tonsils removed
Does your child have:
seasonal allergies
pet allergies
food allergies
take medications for allergies
asthma
frequent stomach aches
frequent headaches
frequent ear aches
frequent neck aches
frequent runny nose
frequent sore throat
trouble swallowing pills
dry or chapped lips
sore teeth or gums
sores in mouth
While sitting around (watching TV, sitting in the car, etc.), does your child:
put “things” in the mouth often
lick or suck their lips
have the lips apart
stick out or dart the tongue out
have the tongue resting between teeth
lean the cheek on a hand
breathe with mouth open during the day
make noises when breathing
have trouble sitting still
While talking, does your child:
talk very fast
talk very slowly
gasp for air
have a lisp
Has your child worked with a speech therapist?
*
Yes
No
During a meal, does your child:
gasp for air while eating
stick tongue out between teeth when swallowing
stick the tongue out to meet the drinking glass
drink a lot while eating
make noises when chewing
have a messy eating pattern
take a breath before drinking
puff the cheeks out when drinking
make the lips purse when swallowing
make the chin “crinkle” when swallowing
bob the head when swallowing
have trouble sitting still
avoid certain textures of food (picky eater)
Does/Did your child breastfeed?
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No
1-3 months
3-6 months
6-9 months
9-12 months
Over a year
Over 2 years
Does/Did your child have complications or challenges with breastfeeding?
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Yes
No
Does/Did your child bottle feed?
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Yes
No
How long did they bottle feed?
Does/did your child:
Currently uses a pacifier
Currently sucks fingers of thumb
Has other oral habits
Used a pacifier in past
Sucked fingers of thumb in past
Used to have other oral habits in past
As an infant did your child have feeding difficulties?
*
Yes
No
Please describe feeding difficulties:
As a baby, is/was your child:
early to get teeth
late to get teeth
hard to feed
refusing or difficulties chewing food
prone to ear infections
Additional notes / concerns / info
Submit