Helpful resources are just a click away. Patient Intake Forms Adult Intake Adult Patient Intake First Name: Middle Initial: Last Name: Suffix: D.O.B.: Gender: Marital Status: City: Street Address: State: Zip: Preferred Phone Number: (###) ### #### Email: Whom shall we contact in a medical emergency? Phone #: Whom may we thank for referring you to me? Describe the problem about which you are most concerned about? How long have you had this problem? Does anything make it better or worse? Is this problem currently giving you pain? Yes No If yes, where, and how much pain? What result would you like to achieve through myofunctional therapy? Medical History *Please list age at diagnosis and any additional details* Current Primary Physician: Phone Number: (###) ### #### Current Dentist: Phone Number: Current Orthodontist: Phone Number: Any Other Specialists? Any Other Specialists? Yes No If yes, who? Would you like to inform either provider about your treatment? Yes No Has your child ever had surgery? Yes No f yes, please check all that apply. Lingual Frenum Restriction (tongue tie) Labial Frenum Restriction (lip tie) Buccal Frenum (cheek tie) Previous surgeries? Yes No If yes, please provide details Any other medical history that you would like me to know? Are you currently under medical care for any medical conditions? Yes No If so, please provide me with details. Do you take medications, including over the counter and supplements? Yes No If yes, please list the name and dosage below. Medicine Name - Dose Have you ever had an allergic reaction to any medications and/or substances? Yes No If yes, please list them below. Medication / Substance Description of Reaction Do you suffer from any seasonal allergies? Yes No If yes, please list them: Do you currently have or have had a history of any pain, medical disorders or diseases? Yes No If yes, please check all that apply *It is especially important to know if you had any of these as a child* Pain in the teeth or gums Frequent headaches or migraines High/Low B.P. Pain in the joints of jaw Neck pain Anemia Trouble chewing Numbness in arms or hands Asthma Trouble speaking Paralysis / loss of sensation Emphysema Trouble swallowing Snoring COPD / Shortness of Clicking/Grinding of jaw joints Daytime sleepiness breath Pain when opening/closing jaw Frequent awakening Chest pain Difficulty opening/closing jaw Tooth grinding while sleeping Arthritis Pain inside of the ear Obstructive sleep apnea Hepatitis Clogged or stuffy ears Restless leg syndrome HIV / AIDS Difficulty hearing Nasal congestion Tuberculosis Ringing in ears Nasal drainage Mononucleosis Ear infections Strep infections Bronchitis Sinus infections Gastric reflux Pneumonia Do you suffer from any sleeping disorders or use any devices to assist you in sleeping? Yes No If yes, please answer the following questions: Have you tried using a dental device for OSA or snoring? Yes No If yes, which? Have you tried using a Continuous Positive Air Pressure (C-PAP) device? Yes No If no, please indicate why: Are you currently pregnant? Yes No If yes, when is the due date? Have you gone through menopause? Yes No Are you currently having any dental work done? Yes No Have you ever worn a dental splint? Yes No Do you currently smoke? Yes No Used to If yes, please indicate the following: Number of packs a day Years smoking Do you drink alcohol? Yes No Any other substances that may impact your health in a significant manner (i.e. illegal, harmful substances): Have you had any major surgeries within the past 10 years? Yes No If yes, please list all major surgeries: Developmental/Feeding History (you may need to research this a bit) Were there any difficulties with your pregnancy or with your delivery? Yes No Was your child breast or bottle fed (circle one)? How long? Were there initial breast/bottle feeding difficulties as an infant/toddler? Difficulty with latch? Poor Milk Supply? Reflux? Were your child’s developmental milestones within normal limits? Yes No Age child sat up? Age child rolled over? Age child crawled? Age child walked? Age child said first word? Age child fed self? Age child began eating solids? Any trouble with speaking, speech sounds? Any sensory concerns as a child? How did transition to solids go? Did child prefer/avoid certain foods and/or consistencies? Did child drink from a sippy cup? Age child drank from a straw? Has your child ever sucked their (check all that apply) Thumb Finger(s) Pacifier When did the habit stop? Does your child have a history of other oral habits? Indicate if still present. Lip licking Lip sucking Cheek biting/sucking Nail biting Other oral habits? How is the child’s general health? History of frequent ear infections? Ear Tubes? Chronic Upper Respiratory Infections/Colds? Any history of speech therapy? Yes No If Yes ,Name/How Long Any history of attending occupational therapy? Yes No If Yes, Name/How Long Any history of physical therapy sessions? Yes No If Yes, Name/How Long Present Eating Habits Are you a fast or slow eater? Yes No Do you drink more than one glass of liquid with meals? Yes No Do you wash down food with liquid during a meal? Yes No Do you chew your food adequately? Yes No Do you choke easily? Yes No Do you gag easily? Yes No Do you belch often? Yes No Do you have digestive problems? Yes No History of reflux? Yes No Are you a noisy eater (lip/tongue smacking)? Yes No Are you a messy eater? Yes No Is there an audible gulping sound when swallowing? Yes No Do you chew with lips apart/mouth open? Yes No Do you avoid any foods due to difficulty chewing? Yes No Do you avoid any foods due to texture issues? Yes No Do you have difficulty swallowing pills? Yes No Dental History Were your baby teeth normal? Yes No Were baby teeth lost at normal ages? Yes No History of any dental anomalies? Yes No Do you have a history of cavities or periodontal disease? Yes No Other oral concerns? Yes No If yes, explain: Have permanent teeth been injured/chipped/extracted? Yes No List any prior orthodontic treatment you have received: Do you experience any of the following: (Check all that apply) Clicking of the jaw Popping of the jaw Pain in the jaw Facial pain Bruxism Day (grinding of the teeth) Bruxism Night (grinding of the teeth) Teeth/jaw clenching (day) Teeth/jaw clenching (night) Other Related Questions Do you usually rest with lips together or open? While sitting idle, do you need to breathe through your mouth or nose? Do you find that your mouth is open while watching TV? Yes No Do you often feel sleepy or tired during the day? Yes No Do you take naps during the day? Yes No Do you fall asleep while involved in a quiet activity? Yes No Additional details with sleep pattern? Yes No Do you have any concerns related to speech or sounds? Yes No Do you have a history of: (check all that apply) Snoring Dry mouth in the morning Sleep with mouth open use sleep medication Unrefreshing/Restless sleep Neck/Shoulder pain Wake up gasping for air Drool during the night (wake up with wet pillows) Difficulty opening or closing your mouth while chewing Additional Questions What is your current profession? Do you work in the home or outside the home? Physical requirements for your job? Anyprevious careers/work environments? Please describe your personality. What do you hope to achieve from this evaluation/treatment? What are your primary goals? Describe the problem you are experiencing and how it interferes with your life? What do you think caused or attributed to this problem? Have you already tried to fix the problem? Is there anything else you would like me to know about you prior to treatment beginning? Thank you! Child Intake Child Patient Form First Name: Middle Initial: Last Name: Date of Birth: MM DD YYYY Gender: Street Address: City: State: Zip: Preferred Phone Number: Email: Parent/Guardian 1 First Name: Last Name: Relationship to minor: Phone Number: Email: Parent/Guardian 1 Profession: Parent/Guardian 2 First Name: Last Name: Relationship to minor: Phone Number: Email: Parent/Guardian 2 Profession: Whom may we thank for referring you to me? What is the reason for visiting my practice? (check/circle all that apply) Snoring/Sleep Issues Frenulum Evaluation Pre/Post Frenectomy Myofunctional Therapy Feeding Concerns Mouth Breathing Tongue Thrust Referred by a dental/medical professional Other reasons (please list): Medical History (Please list age at diagnosis and any additional details) Current Primary Physician: Phone Number: Current Dentist: Phone Number: Current Orthodontist: Phone Number: Any Other Specialists? Do you currently see a sleep specialist? Yes No If yes, who? Would you like to inform either provider about your treatment? Yes No Has your child ever had surgery? Yes No If Yes Lingual Frenum Restriction (tongue tie) Labial Frenum Restriction (lip tie) Buccal Frenum (cheek tie) Previous surgeries? Yes No If yes, please provide details Any other medical history that you would like me to know? Are you currently under medical care for any medical conditions? Yes No If so, please provide me with details. Does your child take any medications, including over the counter and supplements? Yes No If yes, please list the name and dosage below: Medication Name - Dose Has your child ever had an allergic reaction to any medications and or substances? Yes No If yes, please list them below: Medication - Substance Description of Reaction Does your child suffer from any seasonal allergies? Yes No If yes, please list them: Does your child currently have or have had a history of pain, medical disorders/diseases? Yes No If yes, please check all that apply below: Pain in the teeth or gums Pain inside of the ear Noisy Breathing at night Pain in the joints or jaw Clogged of stuffy ears Asthma Trouble chewing Ringing in ears Neck pain Trouble speaking Ear infections Chest pain Trouble swallowing Difficulty hearing Frequent headaches Migraines Snoring Difficulty concentrating Difficulty opening/closing jaw Nasal congestion Daytime sleepiness Open mouth breathing Nasal drainage Strep Infections Tooth grinding while sleeping Obstructive sleep apnea Gastric reflux Difficulty breathing through nose Sinus infections Restless leg syndrome Developmental/Feeding History Were there any difficulties with your pregnancy or with your delivery? Yes No Was your child breast or bottle fed (circle one)? How long? Were there initial breast/bottle feeding difficulties as an infant/toddler? Difficulty with latch? Poor Milk Supply? Reflux? Were your child’s developmental milestones within normal limits? Yes No Age child sat up? Age child rolled over? Age child crawled? Age child walked? Age child said first word? Age child fed self? Age child began eating solids? Any trouble with speaking, speech sounds? Any sensory concerns as a child? How did transition to solids go? Did child prefer/avoid certain foods and/or consistencies? Did child drink from a sippy cup? Age child drank from a straw? Has your child ever sucked their (check all that apply) Thumb Finger(s) Pacifier When did the habit stop? Does your child have a history of other oral habits? Indicate if still present. Lip licking Lip sucking Cheek biting/sucking Nail biting Other oral habits? How is the child’s general health? History of frequent ear infections? Ear Tubes? Chronic Upper Respiratory Infections/Colds? Chronic Upper Respiratory Infections/Colds? Any history of speech therapy? Yes No Name/How Long Any history of attending occupational therapy? Yes No Name/How Long Any history of physical therapy sessions? Yes No Name/How Long Other therapies/interventions? Present Eating Habits for Adolescent Are you a fast or slow eater? Do you drink more than one glass of liquid with meals? Yes No Do you wash down food with liquids during a meal? Yes No Do you chew your food adequately? Yes No Do you choke easily? Yes No Gag easily? Yes No Do you belch often? Yes No Do you have digestive problems? Yes No History of reflux? Yes No Are you a noisy eater (lip/tongue smacking)? Yes No Messy eater? Yes No Is there an audible gulping sound when swallowing? Yes No Do you chew with lips apart/mouth open? Yes No Do you avoid any foods due to difficulty chewing? Yes No Do you avoid any foods due to texture issues? Yes No Do you have difficulty swallowing pills? Yes No Dental History Were baby teeth normal? Yes No Were baby teeth lost at normal ages? Yes No History of any dental anomalies? Yes No Is there a history of cavities or periodontal disease? Yes No Other oral concerns? Yes No Have permanent teeth been injured/chipped/removed? Yes No History of palate expansion? Yes No List any prior orthodontic treatment you have received: Do you experience any of the following: (check all that apply) Clicking of the jaw Popping of the jaw Pain in the jaw Facial pain Bruxism Day (grinding of the teeth) Bruxism Night (grinding of the teeth) Teeth/jaw clenching (day) Teeth/jaw clenching (night) Other Related Questions Do you usually rest with your lips together or open? While sitting idle, do you tend to breathe through your mouth or nose? Do you find that your mouth is open while watching TV or on computer? Yes No Do you often feel sleepy or tired during the day? Yes No Do you take naps during the day? Yes No Do you fall asleep when involved in a quiet activity (watching TV, reading, etc.)? Yes No Additional details with sleep pattern? Do you have any concerns related to your speech or pronunciation? Yes No Do you have a history of: (check all that apply) Snoring Mouth breathing during day Sleep with mouth open Use sleep medication Dry mouth in the morning Unrefreshing/Restless Sleep Neck/Shoulder pain Wake up gasping for air Drool during the night (wake up with wet pillow) Difficulty opening or closing your mouth while chewing What is your current profession? Do you work in the home or outside the home? Physical requirements for your job? Physical requirements for your job? Yes No Any previous careers/work environments? Please describe your personality? What do you hope to achieve from this evaluation/treatment? What are your primary goals? Describe the problem you are experiencing and how it interferes with your life? What do you think caused or attributed to this problem? What have you already tried to fix the problem? Is there anything else that you would like me to know about you prior to treatment beginning? Parent/Guardian Signature Parent/Guardian Name (Print) Date Thank you! Lamberg Sleep Questionnaire LAMBERG AIRWAY AND SLEEP QUESTIONNAIRE Form 1: STANDARD QUESTIONS * Do you awaken unrefreshed or feel sleepy during the day due to restless sleep? Is your snoring loud enough to disturb others? Have you been aware of your snoring for a long time? Have you been told your breathing stops while asleep? Do you ever wake yourself from sleep feeling that you are choking? Have you ever had a sleep study? Have you tried CPAP? (was the pressure > 10.5 cm? Y/N) Is your BMI > 27? Or is your neck size > 17 men, or > 15.5 women? 2: CARDIOLOGY & VASCULAR * Do you have high blood pressure or take medicine for hypertension? Have you been diagnosed with: CAD, Stroke, Congestive Heart Failure, A Fib, or other health issues? Do you have a pacemaker? Do you have elevated total cholesterol levels? 3: PULMONOLOGY * Have you experienced difficulty breathing during the day? Do you have shortness of breath, even with mild exertion? Have you been diagnosed with COPD or Asthma? Is Asthma worse at night? Do you have a chronic cough, either dry or productive? 4: GASTROENTEROLOGY * Do you experience heartburn or acid reflux at night or in the morning? Have you or your dentist noticed erosion on molars? Do you take heartburn medications, either prescription or over the counter? 5: NEUROLOGY * Do you experience numbness, tingling or pain in your feet or hands or head? Do you ever experience muscle weakness or dizziness or difficulty with coordination? 6: ENDOCRINOLOGY * Have you been diagnosed with diabetes or hypothyroidism? Have you unexpectedly gained or lost weight lately? Have you gone through menopause? Are you on HRT? Do you experience repetitive limb movements or jerks in sleep, urges to move legs, or night sweats? 7: OTOLARYNGOLOGY Do you have difficulty breathing through your nose? Do you experience a dry mouth upon awakening? Do you have allergies that make nasal breathing difficult? Is post nasal drip a frequent problem? 8: UROLOGY * Do you experience erectile dysfunction? Experience decreased interest in sex or have you taken medications to enhance sexual performance? Do you ever leak urine involuntarily? Do you have to urinate several times at night, or have you been diagnosed with BPH? 9: DENTAL (BRUXISM, TMD, PERIODONTICS, ORTHODONTICS) * Do you grind your teeth while sleeping? Do your front teeth have a worn look? Have you had jaw muscles or joint pain, ringing in your ears, vertigo, or dizziness? Have you been diagnosed with periodontitis (gum disease)? Are your teeth very crowded or crooked? 10: PSYCHOLOGY & PSYCHIATRY * Are you irritable upon waking in the morning? Do you experience insomnia? (either falling asleep or maintaining sleep) Do you experience: depression, PTSD, memory or concentration problems? Do you take medications for any of these conditions? 11: RHEUMATOLOGY * Have you ever been diagnosed with Gout? Have you ever been diagnosed with Rheumatoid Arthritis? 12: CHRONIC PAIN * Do you often wake up with headaches or have chronic headaches? Do you experience any chronic pain anywhere in your body? Do you take medications for pain on a daily basis? 13: PEDIATRICS (EXCLUDE FROM SCORING) * Do you know any children who are mouth breathers, or who make any sleep breathing sounds? Do you know any children with bedwetting problems? TOTAL SCORE: Suspicion Level (Items Checked): 1 LOW 2-3 MODERATE 4+ HIGH Name * First Name Last Name Date * MM DD YYYY Thank you! Downloadable Resources Adult Patient Child Patient Lamberg Questionnaire Full Checklist Recommended Products
