Child New Patient Information & History
Patient's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Sex
*
Male
Female
Home Phone
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
T-Shirt Size
*
Parent/Guardian 1 Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Occupation
*
Home Address (If different from above)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Guardan 2 Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Occupation
*
Home Address (If different from above)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Other Guardian's Name
*
First Name
Last Name
Relation
*
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Home Address (If different from above)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Who can we thank for referring you?
*
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Health Care Professional(s)
Dentist's Name
*
First Name
Last Name
Dentist's Phone Number
*
Please enter a valid phone number.
Physician's Name
*
First Name
Last Name
Physician's Phone Number
*
Please enter a valid phone number.
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Dental Insurance Information
Do you have dental insurance?
*
Yes
No
Name of Policy Holder
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Employer
*
Relationship to Patient
*
Employer's Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Insurance Company
*
Member ID Number
*
Group Number
*
Insurance Company Phone Number
*
Please enter a valid phone number.
Insurance Company Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Pediatric Sleep Questionnaire: Sleep-Disordered Breathing Subscale
Please answer these questions regarding the behavior of your child during sleep and wakefulness. The questions apply to how your child acts in general during the past month.
While sleeping, does your child: Snore more than half the time?
*
Yes
No
Don't Know
While sleeping, does your child: Always snore?
*
Yes
No
Don't Know
While sleeping, does your child: Snore loudly?
*
Yes
No
Don't Know
While sleeping, does your child: Have "heavy" or loud breathing?
*
Yes
No
Don't Know
While sleeping, does your child: Have trouble breathing, or struggle to breathe?
*
Yes
No
Don't Know
Have you ever seen your child stop breathing during the night?
*
Yes
No
Don't Know
Does your child: Tend to breathe through the mouth during the day?
*
Yes
No
Don't Know
Does your child: Have a dry mouth on waking up in the morning?
*
Yes
No
Don't Know
Does your child: Occasionally wet the bed?
*
Yes
No
Don't Know
Does your child: Wake up feeling unrefreshed in the morning?
*
Yes
No
Don't Know
Does your child: Have a problem with sleepiness during the day?
*
Yes
No
Don't Know
Has a teacher or other supervisor commented that your child appears sleepy during the day?
*
Yes
No
Don't Know
Is it hard to wake your child up in the morning?
*
Yes
No
Don't Know
Does your child wake up with headaches in the morning?
*
Yes
No
Don't Know
Did your child stop growing at a normal rate at any time since birth?
*
Yes
No
Don't Know
Is your child overweight?
*
Yes
No
Don't Know
This child often: Does not seem to listen when spoken to directly.
*
Yes
No
Don't Know
This child often: Has difficulty organizing tasks and activities.
*
Yes
No
Don't Know
This child often: Is easily distracted by extraneous stimuli.
*
Yes
No
Don't Know
This child often: Fidgets with hands or feet or squirms in seat.
*
Yes
No
Don't Know
This child often: Is "on the go" or often acts as if "driven by a motor".
*
Yes
No
Don't Know
This child often: Interrupts or intrudes on others (eg., butts into conversations or games).
*
Yes
No
Don't Know
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Notice of Privacy Practices
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Health Information Access
Note: If you wish to add or teminate information access to or from the list below, you must submit your request in writing to our office.
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number
*
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number
*
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number
*
Please Provide Name, Relationship, and Last 4-Digits of S.S. Number
*
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Signature
Parent/Guardian Signature
*
Clear
Date Submitted
*
-
Month
-
Day
Year
Date
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