New Patient Form

New Patient Form - Adult
Your name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address*
Please bill my PRIMARY insurance policy:

Yes
Please upload photos of the FRONT & BACK of PRIMARY insurance card (if applicable).*

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Cancelof
Date of birth of PRIMARY card holder.*

MonthDayYear
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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Cancelof
Date of birth of SECONDARY card holder.*

MonthDayYear
Date
I will be 'self pay'.*

YesNo
Referred by*
Current concerns*
General doctor:*
Town general doctor is located:*
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
Feeding:*

Currently packs food in cheeks like a chipmunkHistory of packing food in cheeks like a chipmunkCurrently spits out foodHistory of spitting out foodCurrent sensory concerns with texturesHistory of sensory concerns with texturesCurrently a slow eater (doesn’t finish meals)History of slow eating (didn't finish meals)Currently grazes on food throughout the dayHistory of grazing on food throughout the dayCurrently chokes or gags on foodHistory of choking/gagging on foodCurrently won’t try new foodsHistory of not trying new foodsCurrently eats/chews noiselyHistory of eating/chewing noiselyCurrently pocketsHistory of pocketingCurrently eats too fastHistory of eating too fastConcerns with weight gainHistory of concerns with weight gainCurrently a picky eaterHistory of picky eatingHistory of concerns with growth curveNone of the above
Please add any specific details or comments regarding your eating habits.
Habits:*

Currently bites nailsHistory of biting nailsCurrently bites cheeksHistory of biting cheeksCurrently bites lipsHistory of biting lipsCurrently sucks or chews on object(s)History of sucking/chewing on object(s)None of the above
Please add any specific details or comments regarding your habits.
Dental history:*

Currently wears night guardHistory of wearing night guardCurrent TMJ concernsHistory of TMJ concernsCurrently uses orthodonticsHistory of orthodonticsOrthodontic relapseHistory of extractionsHistory of crownsHistory of fillingsNone of the above
Please add any specific details or comments regarding your dental history.
Sleep issues:*

Currently sleeps in strange positionsHistory of sleeping in strange positionsCurrently kicks and flails around at nightHistory of kicking/flailing around at nightCurrently wakes up easily or oftenHistory of waking up easily or oftenCurrently wakes up tired and not refreshedHistory of waking up tired and not refreshedCurrently grinds teeth while sleepingHistory of grinding teeth while sleepingCurrently sleeps with mouth openHistory of sleeping with mouth openCurrently gasps for air or stops breathing (sleep apnea)History of gasping for air or stopping breathing (sleep apnea)Currently breathes heavyHistory of breathing heavyCurrently breathes loudlyHistory of breathing loudlyCurrently suspects sleep apneaHistory of suspecting sleep apneaCurrently snores while sleepingHistory of snoring while sleepingDiagnosed with sleep apnea or UARSSleep study completedNone of the above
Please add any specific details or comments regarding your sleep.
Speech concerns or history:*

Current frustration with communicationHistory of frustration with communicationCurrently difficult to understand by outsidersHistory of being difficult to understand by outsidersCurrent difficulties speaking fastHistory of difficulties speaking fastCurrent difficulties getting words out (groping for words)History of difficulties getting words out (groping for words)Currently stuttersHistory of stutteringCurrently speech is harder to understand in long sentencesHistory of speech being harder to understand in long sentencesCurrently mumbles or speaks softlyHistory of mumbling or speaking softlyCurrent trouble saying some soundsHistory of trouble saying some soundsSpeech delayPrevious Speech TherapyNone of the above
Please add any specific details or comments regarding your speech.
Breathing issues:*

Currently breathes with mouth openHistory of breathing with mouth openCurrently has asthma issuesHistory of asthma issuesCurrently has allergiesHistory of allergiesCurrent noisy/audible breathingHistory of noisy/audible breathingCurrently frequently yawns/sighsHistory of frequent yawns/sighsCurrent dry, chapped lipsHistory of dry, chapped lipsCurrent halitosis (bad breath)History of halitosis (bad breath)None of the above
Please add any specific details or comments regarding your breathing.
Other related issues:*

Current neck or shoulder pain/tensionHistory of neck or shoulder pain/tensionCurrent TMJ pain, clicking or poppingHistory of TMJ pain, clicking or poppingCurrent headaches or migrainesHistory of headaches or migrainesCurrent strong gag reflexHistory of strong gag reflexCurrent mouth open/mouth breathing during the dayHistory of mouth open/mouth breathing during the dayTonsils or adenoids removed previouslyEar tubes previouslyCurrent reflux (medicated or not)History of reflux (medicated or not)Currently hyperactive/inattentiveHistory of hyperactivity/inattentionCurrently constipatedHistory of constipationNone of the above
What are your goals and desired outcomes for the evaluation and possible therapy program?*
Tell us a little about you!
Do you use Social Media?

YesNo
What Social Media platforms do you use?
Do you participate in these activities for fun?

ReadingPodcastsOther
Anything else we need to know?
Today's date*

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New Patient Form - Adult