Child Name(Required) Birthdate MM slash DD slash YYYY Parent/Guardian Name How did you hear about our office? What is your chief concern?What are your goals for your child’s oral and systemic health?What is your child’s bedtime routine?Does your child have any issues going to bed or falling asleep? Yes No Does your child wake up often during the night after falling asleep? Yes No Does your child sleep in a dark room? Yes No Does your child have an irregular bedtime? Yes No Does your child have irregular wake times? Yes No Does your child’s bedtime/wake time differ greatly between weekdays and weekends? Yes No Does your child have difficulty breathing at night while sleeping? Yes No Does your child snore? How often? Can you hear your child breathing when they are sleeping? How often? Does your child sleep with their mouth open? How often? Does your child have regular nightmares, sleep walk or have any other unusual sleep behaviors? Does your child wet the bed? If so, how often? Does your child have a dry mouth when they wake up in the morning? Yes No Does your child find it difficult to wake in the morning? Yes No Does your child wake feeling unrefreshed in the morning? Yes No Does your child seem overly tired or take excessive naps during the day for their age? Yes No What does your child eat for a typical meal?Breakfast?Lunch?Dinner?Snacks? Add RemoveAre there any foods that you avoid giving to your child? What does your child drink during the day? At night? Would you consider your child a picky eater? Yes No Does your child eat animal products? Which ones? How frequently? Does your child chew with their mouth closed? Yes No Does your child rest with their mouth open during the day? How often? Does your child have difficulty organizing tasks and activities for their age? Yes No Does your child appear to not listen when spoken to directly? Yes No Does your child get easily distracted, fidget or struggle to sit still? Yes No Is your child often tired or do they have a hard time concentrating? Yes No Was your child born via C-section? Yes No Does your/has your child ever sucked their thumb? How often? Does your/has your child ever used a pacifier? How often? Does your/has your child ever used a bottle? How often? Has your child ever had a lip tie release? If so, when? Has your child ever had a tongue tie release? If so, when? Is your child’s overall growth slower than the average for their age? Yes No Is your child overweight? Yes No Does your/has your child ever had any speech issues? If so, when? How often is your child congested? How often does your child get sick? What is your child’s oral hygiene routine? What toothpaste does your child use? Have you noticed any cavities or white/brown spots on your child’s teeth? Yes No Does your child have eczema? Yes No Does your child have asthma? Yes No Does your child have crooked teeth? Yes No Do you notice your child has poor posture? Yes No Does your child complain of headaches? Yes No Does your child complain of neck or back pain? Yes No Does your child have pain in their stomach? Yes No Does your child get constipated? Yes No How often does your child poop per day?
