Pediatric Health History

Answer to the best of your ability; we will elaborate on these questions at your child's initial appointment.

Breathing:

Patient First Name *

Patient Last Name *

Patient date of birth *

Address

Street Address

City

State

Country

Postal Code

Responsible Party *

What concerns do you have for your child that brought you to inquire about myofunctional therapy?

May we thank anyone for referring you to our practice?

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Health History

Does your child have any conditions, diagnoses, suspected ailments, etc?

List any medications and supplements your child is taking:

Who is your child's doctor?

Other physicians or professionals involved in your child's health care:

List any allergies:

Does or did your child participate in any therapies not listed above (speech, chiro, etc)?

Has your child had any significant injuries or surgeries?

Any other health history notes?

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Sleep

Where does your child sleep?

What position do they usually sleep in?

Do they breathe through their nose or mouth at night?

Nose

Mouth

Mixed

Do they wake feeling well rested?

Yes

No

Sometimes

Have they ever had a sleep study?

No

Not yet, but planning to, or it has been recommended

Yes

Does your child use any sleep aids or devices?

Yes

No

They used to or it has been recommended

Any other sleep notes?

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Breathing

Can your child blow their nose?

Yes

No

Any other breathing notes?

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Dental Health

Has your child seen a dentist?

No

Yes

Has your child seen an orthodontist?

No

No, but it has been recommended

Yes

How would you describe your child's general dental health and history?

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Oral Habits + Function

If known, in what position is your child's tongue at rest?

Any other notes about oral habits and function? If an oral habit was or is present, please describe:

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Head and Neck

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Other

How would you describe your child's posture?

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Birth + Early Childhood

Any other notes about infancy/childhood?

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Family History

Please note any family history involving any of the above concerns; including history of oral ties, orthodontic intervention and sleep habits:

Is there anything else you would like us to know?