New Patient Form

Tell Us About Your Child

Today's Date:   Date*   
Best phone to reach you at:   Phone Number*   Mobile    Home    Work    
Birthdate:   Birthdate*   Child's Age:   Age*   
Nickname:   Nickname   Male    Female   
School: School Name Grade: Grade
Child's Home Address:   Street Address      City   State   Zip   
What patient or physician can we thank for referring you?      

Parent's Information

Parent's Marital Status: 
Married   Divorced   Widowed   Remaried   Single   Partnered   
Parent 1:   First Name*   Last Name*   Social Security #:   SS number   
Birthdate:   Birthdate*   Email Address:   Email   
Employer:   Employer   Home Phone:  Phone Number   
Work Phone:  Phone Number   Cell Phone:  Phone Number   

Parent 2:   First Name*   Last Name*   Social Security #:   SS number   
Birthdate:   Birthdate*   Email Address:   Email   
Employer:   Employer   Home Phone:  Phone Number   
Work Phone:  Phone Number   Cell Phone:  Phone Number   

Does/did the child have any of the following habits?
Yes   No* Lip Sucking/Biting
Yes   No* Mouth Breather  
Yes   No* Used Pacifier
Yes   No* Nursing Bottle Habits
Yes   No* Clenching/Grinding Teeth
Yes   No* Nail Biting
Yes   No* Speech Problems
Yes   No* Tongue Thrust
Yes   No* Tongue/Cheek Biting
Yes   No* Thumb/Finger Sucking
Yes   No* Chewing On Objects
Yes   No* Breast Fed

Has the child had/experienced any of the following:
Yes   No* Abnormal Bleeding
Yes   No* Anemia  
Yes   No* Any Hospital Stay/Operations
Yes   No* Asthma
Yes   No* Autism Spectrum
Yes   No* Birth Defects
Yes   No* Blood Transfusions
Yes   No* Cancer
Yes   No* Cerebral Palsy
Yes   No* Chronic Ear Infections/Tubes
Yes   No* Cystic Fibrosis
Yes   No* Delayed Speech Development
Yes   No* Developmental Delay
Yes   No* Diabetes
Yes   No* Down Syndrome
Yes   No* Emotional/Psychiatric Problems
Yes   No* Epilepsy
Yes   No*   Food Allergies             
Yes   No*   G-Tube Feeding
Yes   No*   Hearing Loss/Impairment
Yes   No*  Heart Condition/Murmur
Yes   No*   Hepatitis
Yes   No*   HIV/AIDS
Yes   No*   Hyperactivity/ADHD
Yes   No*   Kidney Disease
Yes   No*   Learning Disabilities
Yes   No*   Liver Disease
Yes   No*   Muscular Dystrophy
Yes   No*   Radiation Therapy
Yes   No*   Rheumatic Fever
Yes   No*   Seizures
Yes   No*   Seasonal Allergies
Yes   No*   Sickle Cell Anemia
Yes   No*   Skin Disorders
Yes   No*   Sleep Apnea/Snoring
Yes   No*   Spina Bifida
Yes   No*   Tonsillitis
Yes   No*   Tuberculosis (TB)
Yes   No*   Tumors
Yes   No*   Syndrome (specify)