New Patient Form - Child
Patient's name
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First Name
Last Name
Patient's date of birth
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Month
-
Day
Year
Date
Parent/Guardian #1
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First Name
Last Name
Parent/Guardian #1 address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address
*
Is this person responsible for billing?
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Yes
No
Other
Is this the minor's primary address?
Yes
No
Other
Parent/Guardian #2
First Name
Last Name
Parent/Guardian #2 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address
Is this person responsible for billing?
*
Yes
No
Other
Is this the minor's primary address?
*
Yes
No
Other
Please bill my PRIMARY insurance policy:
Yes
Please upload photos of the FRONT & BACK of PRIMARY insurance card (if applicable).
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Browse Files
Cancel
of
Date of birth of PRIMARY card holder.
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Month
-
Day
Year
Date
I would like to also use my SECONDARY insurance policy:
Yes
Please upload photos of the FRONT & BACK of SECONDARY insurance card (if applicable).
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Browse Files
Cancel
of
Date of birth of SECONDARY card holder.
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Month
-
Day
Year
Date
I will be 'self pay'.
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Yes
No
Referred by
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Current concerns
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Full Term Pregnancy?
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Type of Delivery
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Unexpected outcomes during the birth/delivery?
Birth weight
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Birth length
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Pass newborn hearing screening?
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Yes
No
Unsure
Pediatrician:
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Town Pediatrician is located:
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Dentist:
Please list the name and phone for any other medical professionals including, but not limited to the following: Orthodontist, Allergist, ENT, Occupational Therapy, Physical Therapy, Speech Pathologist, Chiropractor, Craniosacral Therapist
Any food or seasonal allergies?
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Feeding:
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Currently breastfed
Previously breastfed
Attempted breastfeeding
Currently bottle fed
Supplementing with bottles
Previously bottle fed
Currently tube fed (G-tube or NG tube)
Previously tube fed (G-tube or NG tube)
Currently frustration when eating
Previous frustration when eating
Current difficulty transitioning to solid foods
Previous difficulty in transitioning to solid foods
Current slow eater (doesn’t finish meals)
Previous slow eater (doesn’t finish meals)
Currently grazes on food throughout the day
History of grazing on food throughout the day
Currently packs food in cheeks like a chipmunk
History of packing/holding food in cheeks
Currently pockets food in the mouth
History of pocketing food in the mouth
Currently chokes or gags on food
History of choking/gagging on food
Currently spits out food
History of spitting out food
Currently won’t try new foods
History of caution when trying new foods
Currently noisy eating/chewing
History of noisy eating and chewing
Currently eats quickly
History of eating quickly
Current concerns with growth curve
History of concerns with growth curve
Current concerns with weight gain
History of concerns with weight gain
Current concerns with picky eating
History of concerns with picky eating
Current concerns with feeding issues
History of concerns with feeding issues
Current sensory concerns with food
History of sensory concerns with food
Please add any specific details or comments regarding your child's feeding history.
Habits:
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Currently uses pacifier
History of pacifier use
Currently sucks thumb/digit
History of sucking thumb/digit
Uses sippy cup
History of using sippy cup
Currently bites nails
History of biting nails
Currently bites cheek
History of biting cheek
Currently bites lip
History of biting lip
Currently sucks or chews on objects
History of sucking or chewing on objects
None of the above
Please add any specific details or comments regarding your child's habits.
Dental history:
*
Current TMJ concerns
History of TMJ concerns
Currently uses night guard
History of night guard use
Currently uses orthodontics
History of orthodontic use
History of fillings
History of crowns
History of extractions
Orthodontic relapse
None of the above
Please add any specific details or comments regarding your child's dental history.
Sleep issues:
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Currently sleeps in strange positions
History of sleeping in strange positions
Currently kicking/flailing around at night
History of kicking and flailing around at night
Currently wakes easily or often
History of waking easily or often
Currently wets the bed
History of wetting the bed
Currently wakes up tired and not refreshed
History of waking up tired and not refreshed
Currently grinds teeth while sleeping
History of grinding teeth while sleeping
Sleeps with mouth open
History of sleeping with mouth open
Currently gasps for air or stops breathing (sleep apnea)
History of gasping for air or stopped breathing (sleep apnea)
Suspected sleep apnea
Diagnosed with sleep apnea or UARS
Currently breathes heavy
History of breathing heavy
Currently breathes loudy
History of breathing loudly
Currently snores while sleeping
History of snoring while sleeping
Sleep study completed
None of the above
Please add any specific details or comments regarding your child's sleeping.
Speech issues:
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Current frustration with communication
History of frustration with communication
Currently difficult to understand by parents
History of difficultly understanding by parents
Currently difficult to understand by outsiders
History of difficulty understanding by outsiders
Current difficulties speaking fast
History of difficulties speaking fast
Current difficulties getting words out (groping for words)
History of difficulties getting words out (groping for words)
Currently stutters
History of stuttering
Currently hard to understand in long sentences
History of hard to understand in long sentences
Currently mumbles or speaks softly
History of mumbling or speaking softly
Currently “baby talks”
History of "baby talking"
Current trouble with saying some sounds
History of trouble with saying some sounds
Current speech delay
History of speech delay
Do you understand your child when other less familiar people do not?
Previous speech therapy
None of the above
Please add any specific details or comments regarding your child's speech.
Breathing issues:
*
Currently breathes with mouth open
History of breathing with mouth open
Currently has asthma issues
History of asthma issues
Currently has allergies
History of allergies
Currently breathes noisely/audibly
History of breathing noisely/audibly
Currently yawns/sighs frequently
History of yawning/sighing frequently
Currently has dry, chapped lips
History of dry, chapped lips
Currently has halitosis (Bad breath)
History of halitosis (bad breath)
None of the above
Please add any specific details or comments regarding your child's breathing.
Other related issues:
Current neck or shoulder pain/tension
History of neck or should pain/tension
Current TMJ pain, clicking or popping
History of TMJ pain, clicking or popping
Currently has headaches or migraines
History of headaches or migraines
Currently has strong gag reflex
History of strong gag reflex
Currently has reflux (medicated or not)
History of reflux (medicated or not)
Currently hyperactive/inattentive
History of hyperactivity/inattention
Currently constipated
History of constipation
Tonsils or adenoids removed previously
Ear tubes previously
What are your goals and desired outcomes for the evaluation and possible therapy program?
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What is your child's favorite TV show?
What is your child's favorite food?
What is your child's favorite outside activity?
Does your family have a pet? If so, what kind(s)?
Do you (the caregiver) read books or listen to podcasts?
What languages do you (the caregiver) speak?
Tell us a little about your family!
Your name
*
First Name
Last Name
Relation to patient
*
Today's date
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