New Patient Information Form (Child)

Parent Concerns

Parent Concerns (Check any that apply)*

Speech Articulation- FOR EXAMPLE: Speech Sounds, Child is Hard to Understand, Lisp, Speech Sound Errors, Says Sounds Wrong, Talks too Fast, Mumbles, Slurred Speech, Unclear Speech, Apraxia, Motor Planning, Phonological Impairments
Delayed Talker- FOR EXAMPLE: Barely Talking, Not Talking Yet, Language Delayed
Receptive Language Challenges- FOR EXAMPLE: Comprehension Issues, Auditory Processing Challenges, Does Not Understand What is Said, Cannot Follow Directions Well, Poor Listening Skills
Expressive Language Challenges- FOR EXAMPLE: Grammar Issues, Sentences Not Correct, Hard Time Telling A Story, Hard Time Expressing Oneself
Reading Challenges- FOR EXAMPLE: Dyslexia, Hard Time Sounding Out or Decoding Words
Social Skills- FOR EXAMPLE: Pragmatics, Eye Contact, Hard Time Making Friends, Off Topic, Hard Time Initiating With Peers, Inappropriate with Peers
Stutters- FOR EXAMPLE: Repeats sounds and words
Voice Sounds Different FOR EXAMPLE: (hoarse, raspy, pitch is off, etc.)
Orofacial Myofunctional or Tongue Thrust (separate or in addition to speech sound errors)-FOR EXAMPLE: Mouth Is Open At Rest, Lips Rest Apart, Tongue Sticks Forward Throughout The Day, Sucks Thumb/Fingers/Objects, Chews Nails, Swallowing and Eating Challenges, Orofacial Myology, Myofunctional Therapy, Dentist/Orthodontist Has Concerns, Dental Issues, Sleep-Related Breathing Issues (snoring, sleep apnea)
Feeding Challenges-FOR EXAMPLE: challenges with feeding skills including issues with current diet, limited food intake, limited intake of a variety of foods and textures, mealtime routines/patterns, limited intake volumes, and behaviors at meals, difficulty with chewing, manipulating food in the mouth, or swallowing, oral-sensory challenges with feeding that impacts your child's ability to accept new foods including vision, smell, touch, and taste.
Occupational Therapy Related Challenges-FOR EXAMPLE: fine motor issues, challenges with tool use (using a pencil, crayons, scissors, utensils), challenges with dressing (buttons, zippers, snaps, shoe tying), gross motor difficulties (walking, running, ball play, stair use, climbing, play structure), sensory challenges (including sensory difficulties using play doh, sand, glue, water, issues with physical contact with peers and adults)
Other

If "Other", please explain.*

Please describe in detail your specific speech/language/orofacial-myofunctional, occupational therapy, or academic related concerns with your child.*

In terms of your child’s development, what would you like your child to be able to do that he/she is not doing now?.*

Please list a few of your child’s strengths and likes/areas of interest.*

Please list a few of your child’s weaknesses.*

Prior Therapy

Has your child had a speech/language/orofacial-myofunctional or occupational therapy ASSESSMENT before?*

No
Yes

*

Where	When

Please describe the results*

Has your child ever received speech, myofunctional, or occupational THERAPY before?*

No
Yes

*

Where	When

Is your child currently receiving speech, myofunctional, or occupational THERAPY?*

No
Yes

*

Where	When

If your child currently or in the past has had speech therapy, myofunctional therapy, or occupational therapy, please describe what was addressed in the therapy.

Does your child receive any special education services in school (e.g., speech therapy, OT, APE, special day class, resource support, learning center)?*

No
Yes

Does you child have an IEP at school?*

No
Yes

School*

Services on IEP*

Speech
OT
Learning Center/Resource/Academic/Special Day Class
APE

Bilingualism & Multiple Languages

What is your child’s primary language?*

What language is spoken in the home?*

Is your child considered bilingual, or has your child been exposed to any other languages?*

No
Yes

Describe how your child has been exposed to any other languages?*

Please describe all of the following: what ages, settings, and percent of time your child has been exposed to each language.*

How does your child use each language he/she speaks?*

What percent of the time each day does he/she hear each language currently?*

How was the first langauge developing before the second language was introduced?*

Since learning the second language has the child experienced an emotional trauma or a neurological insult?*

What do you think is your child’s attitude towards speaking English?*

Is your child very social with peers from a similar cultural/linguistic background or with monolingual English-speaking peers?*

Which language does your child speak with siblings?*

If applicable, which language does your child read and write? What percent of the time?*

Were there any changes in the first language after the second language was introduced?*

Where was your child born (what country if not in U.S.A)? How long did your child live there? When and what age did your child come to the U.S.?*

Where has the child received all of his/her schooling? What language(s) was spoken with each school experience?*

Are/were there any tutors or nannys working with your child? What languages does/did that person speak?*

Developmental History

Are you the biological parent(s) of your child?*

No
Yes

Please list any known information on the child’s biological mother, her pregnancy, your child’s birth history and development (age appropriate developmental milestones?) as well as any information on the biological father. Please also describe where the child resided before he/she was adopted.*

Please describe your child’s birth history. Were there any pre-birth problems, injuries, drug use? Were there any complications during the birthing process?*

Was your child breast-fed?*

No
Yes

For how long (ages)?*

Were there any of the following difficulties when breastfeeding?*

Check all that apply

Was your child bottle-fed?*

No
Yes

For how long (ages)?*

Did/does your child use a pacifier?*

No
Yes

For how long (ages and at what times)?*

Has your child used a sippy cup?*

No
Yes

For how long (ages)?*

Does your child drool or have a history of drooling?*

No
Yes

For how long (ages)?*

Has your child sucked his/her thumb or fingers before?*

No
Yes

What ages? How often?*

Has your child sucked on any other items such as clothes, blankets, stuffed animals, pencils, other objects, lips, cheeks, tongue before? Any nail biting? Please list if any of these habits are still occurring or when they stopped.*

What age did your child babble?*

What age were your child's first words?*

What age did your child begin combining words (2 word phrases)?

What age did your child become toilet trained?

What age did your child sit alone?

What age did your child crawl on his/her tummy?

What age did your child creep on his/her hands and knees?

What age did your child pull to stand?

What age did your child walk alone?

Were there any unusual observations during the development of these skills, such as dislike of being on their stomach, not crawling on hands and knees, scooting on their bottom, not responding to sounds, not making sounds to gain attention etc?

Did/do you have any concerns with your child reaching his/her developmental milestones (motor skills, speech skills, social interactions, etc.)?*

Describe the play activities that your child enjoys. Does your child play interactively with his peers? Does your child play independently?

Is there any family history of speech, language, oral-motor, feeding, and/or fine or gross motor difficulties?*

No
Yes

Please describe.*

Health & Medical Information

Has your child suffered any injuries or trauma?*

No
Yes

Please describe.*

Has your child ever had any surgeries or hospitalizations?*

No
Yes

Please describe.*

When and where was your child’s hearing last tested? Please state what the results were?*

Does your child have any allergies?*

No
Yes

Please list and describe.*

Has your child ever been tested for allergies?*

No
Yes

Has your child ever been to an ENT (ear, nose, and throat doctor) or an Otolaryngologist?*

No
Yes

Describe why he/she went to the ENT and the results.*

Is your child on any medication?*

No
Yes

Please list and describe.*

Has your child had recurrent issues with any of the following:*

Check all that apply

Ear infections
Tonsillitis
Strep throat
Gastro-intestinal issues
Asthma
Other:
No recurrent issues with any of the above

Describe your child’s health. Does your child get sick often? List if any of the above are/were recurrent issues:*

Sleep Breathing

Does your child snore at all?*

No
Yes

If yes, please describe how often. Does the snoring wake your child up?*

How would you describe your child's sleep behaviors and alertness throughout the day?*

Check all that apply

Good sleeper
Restless sleeper, tosses and turns, or bed is a mess when wakes up
Tired upon waking
Tires easily
Hyperactive or excessive movement and energy
Moody throughout the day
Other:
No alertness or behavioral concerns/issues

How long has your child been snoring or have had sleep apnea?*

Do you know what started the sleep-disordered breathing issues? Describe.*

Has your child had any treatment for the sleep-disordered breathing issues? Please describe.*

Do your child snore with his/her lips:*

Check all that apply

Open
Closed
Both
Unknown

Does your child snore on his/her:*

Check all that apply

Back
Stomach
Side
Unknown

Do you know if your child stops breathing when he/she is snoring?*

No
Yes

How many hours of sleep on average does your child get each night?*

Is your child a restless sleeper (tosses and turns, bed is a mess when he/she wakes up, etc.). Please describe?*

Does your child kick or have leg or arm jerks at night while sleeping?*

Does your child sweat during sleep?*

No
Yes

Does your child wake up tired?*

No
Yes

Does your child fall asleep during the day or appear hyperactive throughout the day? Please describe.*

Does your child take naps during the day? If yes, how many naps/day and how long is each nap on average?*

Does your child breathe through his/her nose while sleeping?*

No
Yes

Are your child's lips closed when sleeping?*

No
Yes

Do your child have trouble breathing through his/her nose?*

No
Yes

Does your child have:*

Check all that apply

Allergies
Asthma
Frequent colds
Excess mucous, congestion
No respiratory/breathing/congestion concerns

Do your child have his/her tonsils?*

No
Yes

Do your child have his/her adenoids?*

No
Yes

Is your child taking any medication for breathing?*

No
Yes

List the medication(s) for breathing:*

Has your child had any surgery in his/her nose, throat, or mouth?*

What time does your child eat dinner?*

Would you consider this a large meal?*

No
Yes

Does your child snack after dinner?*

No
Yes

Does your child have acid reflux?*

No
Yes

Does your child take medication for reflux? Do you manage the acid reflux in any other way?*

Does your child have a retainer, mouthguard, or any snoring appliance? If yes, how often does he/she wear it?*

Feeding Information

Please describe your child’s feeding history. Were there any feeding difficulties?*

Does your child have any current food restrictions or sensitivities/avoidances?*

No
Yes

Please list and describe.*

Do you have any feeding concerns with your child that may be causing you to seek feeding therapy with us?*

No
Yes

Please list and describe.*

Has your child ever had a feeding tube or does your child currently have a feeding tube?*

Yes
No

List feeding schedule and amounts:*

How have you attempted to address your child's feeding difficulties so far?*

At what age did your child transition to the following foods:

Purees

Dissolvable solids

Mashed solids

Mixed textures

Crunchy solids

Finger foods

What consistency of foods/liquids does your child currently eat?

Approximately how much food does your child eat at each meal?

How long does each meal take approximately?

What are some of your child’s favorite foods?

What foods will your child not eat?

How much milk/formula does your child drink at each meal?

Does your child drink juice? If yes, how much in one day? Is the juice given before, during, or after a meal?

When is your child offered the cup/bottle of formula or milk: during meals, between meals, or all the time?

How many times per day does your child eat?

Does your child snack between meals? If yes, with what foods?

Where does your child eat and how is he/she positioned?

Does your child feed himself/herself? If yes, using what?

Who is present for meals?

Does your child exhibit the following behaviors during meals? Please check all that apply:

crying
gagging
vomiting
holding food in his/her mouth
spitting food out
verbally refusing food
getting down from the table during the meal

Do you think your child has any difficulty with chewing or swallowing foods (other than refusal)? If yes, please describe.

What are your family routines, traditions, and preferences for mealtimes?

What you would like your child to be doing at mealtimes? What foods would you like your child to eat?

Please describe any other feeding problems your child is experiencing.

Dental Development

Does your child have any orthodontia or history of (e.g., braces, palatal expander, etc.)?*

No
Yes

Please describe specifically what appliances and when:*

Has your child's dentist or orthodontist ever commented that he/she may need orthodontia?*

No
Yes

Please describe:*

Does your child clench or grind his/her teeth?*

No
Yes

If yes, describe when (day, night, what circumstances) there is clenching or grinding. If you are seeking therapy with us to treat the clenching/grinding, there are more detailed questions in the Bruxim section toward the end of this document:*

How would you describe your child's overall dental health?*

Good
Fair/Average
Poor

Myofunctional Therapy Information

Was your child referred to us for Myofunctional Therapy, AND/OR was your child referred to us by a dentist/orthodontist or other medical specialist for myofunctional/dental/orthodontic/sleep-breathing issues, AND/OR does your child have any of the following behaviors/issues: tongue thrust, sit with his/her mouth open, clenching/grinding, have a lisp, sit with the tongue between the teeth, jaw pain, consistent snoring/apnea/sleep-related breathing issues, or have he/she had braces or orthodontics that have not worked?*

No
Yes

What kind of water bottle does your child use? Please describe. Is it a free flowing water bottle or one in which he/she has to suck (with a spout, straw, sucking cap, Camelback, etc.)?*

Does your child know how to blow his/her nose well?*

No
Yes

Ask your child the following, or observe these behaviors in your child if he/she is not old enough to answer. If your child is able to think about and answer these questions, this will assist in our assessment. Please try to have your child answer these questions if he/she is able to do so:

When you swallow saliva, do your lips squeeze tight together?*

No
Yes

When you swallow saliva, does your tongue come forward?*

No
Yes

When you swallow saliva, do the sides of your tongue go between your back teeth?*

No
Yes

Do your teeth close when you swallow saliva?*

No
Yes

When eating, do you chew on one side more than the other?*

No
Yes

Do you chew with your lips open?*

No
Yes

Does your tongue move forward or down when you chew?*

No
Yes

Do the sides of your tongue push between the back teeth when you chew?*

No
Yes

After chewing, does the tongue push forward, down, or sideways when you swallow?*

No
Yes

When drinking, does your tongue touch the rim of the glass, bottle, or can?*

No
Yes

When drinking, does your tongue push forward, down, or sideways when you swallow?*

No
Yes

When drinking, do you choke or cough after you swallow?*

No
Yes

At rest, are your lips parted during the day and/or night?*

No
Yes

Do you breathe through your mouth at rest?*

No
Yes

Do you snore?*

No
Yes

When you close your lips, does your chin muscle look bumpy or tight?*

No
Yes

Where does your tongue rest?*

On the floor of the mouth
On the teeth
Between the teeth
Up on the roof
Other

If your tongue rests in a position other than above, please describe:*

Does your tongue feel too large for your mouth?*

No
Yes

Do you have any of the following speech issues:*

Check all that apply

"Lazy speech"
Mumble
Trip over your words
Issues with particular sounds
Other
None

If you have any other speech issues, please describe:*

Does your jaw do any of the following:*

Check all that apply

Click
Pop
Make any noises
Get stuck in the open or closed position
Other
None

If your jaw has any other issues, please describe:*

Have you ever had any jaw trauma or injuries?*

No
Yes

If you have had any jaw trauma or injuries, please describe the incident(s) and what treatment you received.*

Do you have any pain in your jaw, temples, or face?*

Yes
No

Bruxism: Clenching or Grinding Information

Does your child have issues with bruxism (clenching or grinding of the teeth) during the day and/or night?*

No
Yes

Are you seeking treatment from us for the bruxism (clenching or grinding of the teeth) during the day and/or night?*

No
Yes

Bruxism: Clenching/Grinding

Bruxism is defined as the rhythmic or spasmodic grinding or clenching of the teeth in other than chewing movements of the mandible/lower jaw, both at night and during the day. There is no one cause for clenching and grinding. Bruxism has multiple causative factors which the following questions will attempt to uncover. Please ask your child the following or answer the following questions for your child.

Do you eat:*

Check all that apply

Breakfast
Lunch
Snack
Dinner
Dessert

What time do you typically eat dinner?*

What do you typically eat for dessert?*

What time do you eat dessert?*

Do you drink anything with caffeine?*

How often do you drink caffeine?*

Do you drink water?*

Do you exercise or participate in sports in the evening?*

No
Yes

What do you typically do in the evening before bed?*

Do you unwind in the evening or wind up?*

What time do you go to sleep?*

How long does it take you to fall asleep?*

When you sleep, do you:*

Check all that apply

Dream
Have nightmares
Walk in your sleep
Talk in
Other
None

Are there any other sleep behaviors that you may have?*

Do you wake in the night?*

No
Yes

How many times?*

Do you know what wakes you?*

Are you aware of any clenching/grinding when you wake in the night?*

No
Yes

Can you go back to sleep?*

No
Yes

How long does it take you to go back to sleep?*

Are you a restless sleeper?*

No
Yes

How often do you get up at night?*

What time do you wake up?*

What wakes you?*

Do you have pain anywhere in your body?*

No
Yes

How do you manage pain?*

Check all that apply

Medication
Massage
Heat/Ice
Specialist
Other

Please describe any other ways you manage pain?*

Do you have any medical conditions?*

Are you taking any medications?*

Do you breathe through your mouth while sleeping?*

No
Yes

When sleeping, do you:*

Check all that apply

Snore
Have heavy breathing
Have sleep apnea
Other
None

Please describe any other sleep-breathing related behaviors you may experience:*

Do you have a night guard or any breathing device?*

No
Yes

Do you currently have any orthodontic appliances?*

Check all that apply

Retainer
Braces
Palatal expander
Head gear
None
Other

Please list and describe any past or current orthodontic appliances:*

What noises might you hear during the night?*

Check all that apply

Please list any other noises you hear at night?*

Do you fall asleep to music or TV?*

No
Yes

Does the phone ring at night?*

No
Yes

Do you sleep alone?*

No
Yes

Do you have any pets in your room?*

No
Yes

Does a dog or cat sleep with you?*

No
Yes

Is the temperature of your room comfortable?*

No
Yes

Is your bed or pillow comfortable?*

No
Yes

Is there plenty of room in your bed?*

No
Yes

Do you sleep on your stomach?*

No
Yes

Do you have darkening window coverings in your bedroom?*

No
Yes

Is there any light in your room while you are sleeping?*

Check all that apply

Please list any other light that may be entering your room at night that you are aware of:*

Are you aware of anything that is not on this questionnaire that disturbs your sleep?*

No
Yes

Are you aware of clenching or grinding your teeth while awake?*

No
Yes

When your mouth is at rest, are your teeth:*

Apart
Together

Do you notice clenching or grinding anytime in particular during the day?*

Check all that apply

Please describe any other particular times you may clench or grind your teeth:*

During the day, do you breathe through your nose or mouth?*

Do you have any:*

Check all that apply

Allergies
Deviated septum
Asthma
Nasal Congestion
Other breathing problems
None

Please describe any other breathing problems you have:*

Do you take any medication for breathing problems?*

What stresses are in your life?*

Do you feel that stress or anxiety contributes to the clenching or grinding?*

No
Yes

Step 1 of 6 - Welcome Packet

Welcome Packet

General Information, Policies, & Procedures

Information Form

Other Documents Relevant To Your Child

Office Locations

Carmel Valley Office

Mission Beach Office (located inside Water and Sports Physical Therapy)

Payment, Insurance, Superbills

Speech Therapy & Occupational Therapy Payment Details:

SAN DIEGO CENTER FOR SPEECH THERAPY PAYMENTS AND INSURANCE/SUPERBILLS

Myofunctional Therapy Payment Details:

TRICARE

Cancellation Policy