Patient Evaluation Questionaire

33%

Date*
Name*
Name
Age*
DOB*
Who may we thank for referring you?
Chief Complaint(s):*
1. Describe pregnancy:*
2. MTHFR Testing?*
- YES
- NO
Explain:
3. Describe birth delivery: (normal, c-section, delayed, epidural, forceps, bruising etc.)*
4. Breast fed? If yes, for how long?*
- YES
- NO
Explain:
5. Painful or noisy breast feeding?*
- YES
- NO
Explain:
6. History of frenectomy or diagnosed tongue tie?*
- YES
- NO
Explain:
7. Visit with lactation consultant?*
- YES
- NO
Explain:
8. Did the baby experience any colic?*
- YES
- NO
Explain:
9. Any bottle feeding?*
- YES
- NO
Explain:
10. At what age were solid foods introduced?*
11. Crawling at what age?*
12. Walking at what age?*
13. Any trouble with fine motor skill development? (tying shoes, coordination, etc.)*
- YES
- NO
Explain:
14. Any childhood diseases?*
15. Vaccinations?*

16. History of any medications or antibiotics?*
17. Any sucking habits? (Thumb, fingers, shirts, blankets, cheeks, pencils, etc.)*
18. Sensory issues? (photo sensitive, noise, textures, etc.)*
- YES
- NO
Explain:
19. Messy eater, gulping while eating, fast/slow?*
- YES
- NO
Explain:
20. Hiccups with regularity?*
- YES
- NO
Explain:
21. Picky eater?*
- YES
- NO
Explain:
22. Any gagging? (pills, foods, drinks, etc.)*
23. Gas or bloating?*
24. Any injuries, scars, surgeries, falls or car accidents? Explain:*
25. Describe sleep? (how long, restless, interrupted, difficulty to fall asleep or wake up, etc.)*
26. History of night terrors?*
27. Bed wetting issues?*
28. Sleep posture? (on back, side, stomach, etc.)*
29. Teeth grinding?*
- YES
- NO
Explain:
30. Snoring?*
- YES
- NO
Explain:

31. Sleep apnea?*
- YES
- NO
Explain:
32. Headaches?*
- YES
- NO
Explain:
33. TMD pain or clicking of joints?*
- YES
- NO
Explain:
34. Ear aches?*
- YES
- NO
Explain:
35. History of ear infections or tubes?*
- YES
- NO
Explain:
36. History of chronic congestion or sinusitis?*
- YES
- NO
Explain:
37. Any problems with tonsils and adenoids? (Removed, chronically swollen, trouble swallowing, etc.)*
38. History of Asthma?*
39. Breathing? (mouth, nasal, congested, difficulty, wheezing, etc.)*
40. Mouth open at night during sleep?*
41. Allergies?*
- YES
- NO
Explain:
42. Any pets?*
- YES
- NO
Explain:
43. Any behavior or social issues? (ADD, ADHD, Autism, Asperger’s, etc.)*
44. Any academic or learning issues?*
45. Activities, sports, musical instruments?*
46. Posture assessment: (forward head posture, slouched, limp, etc.)*
47. Any history of previous orthodontics? Explain:*
48. Gummy smile?*
- YES
- NO

ABOUT US

5350 Topanga Canyon Blvd
Woodland Hills, CA 91364
Current Patients: 818-225-8800
New Patients: 747-318-5448
Fax: 818-225-8826

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