Intake Form Posted on August 17, 2015March 31, 2020 by Chris Intake Form 2020 Client First Name * Client Last Name * Date of Birth * Client Gender * Male Female Age Mother's Name (if applicable) Father's Name (if applicable) Email * Phone (Mobile/Cell) * Phone (Home) Address * City * State * OR WA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK PA RI SC SD TN TX UT VA VT WI WV WY Zip * Referral Source Client's Dentist (Provide dentist's name - if applicable) Client's Orthodonist (Provide doctor's name - if applicable) Permission to contact via email * Yes No Permission to contact via text messaging * Yes No Severe Allergies (list if applicable) Current medications Oral appliances (please list current, past, and planned) Do you play any musical instruments? Yes No Please list the instruments you play: How often do you chew gum? Daily Weekly Rarely Never Current food allergies? Yes No Unsure Please list your food allergies here: Seasonal or environmental allergies? Yes No Suspected Oral habits (sucking, chewing, biting)? Yes, in the past Yes, currently Not aware of any No Do you have any difficulty swallowing pills? Yes No Unsure Do you experience pain in any of the following areas? Face Neck Headaches Jaw Pain OtherOther Tonsils and Adenoids: Tonsils and adenoids, intact Tonsils and adenoids, removed Tonsils removed, only Adenoids removed, only Do you have a history of any of the below? Earaches Ringing in the ear Excessive ear wax Indigestion/discomfort or GI issues of any kind? Yes No Typical breathing pattern Through the mouth With the nose Both Snoring during sleep? Yes No Seen currently or in the past Ear Nose and Throat Doctor Allergist Dentist Orthodontist Oral Surgeon Neurologist Acupuncturist Chiropractor OtherOther Eating Picky Messy Fast Slow Big bites/stuffer Gagging Mouth open Adequately chews food Not aware of any issues Issues as an infant (check all that apply or are suspected) Any injuries or scars? Head Face Neck Please describe your head/face/neck injuries here: Please list additional medical/physical conditions that may have affect on treatment What is your reason for seeking treatment? What are your goals for your treatment? Additional Information If you are human, leave this field blank.