Adolescent Intake Form

Patient Name *

First

Last

Parent or Guardian Name *

First

Last

Phone Number *

Address *

Phone Number *

Email *

While sleeping does your child:

Is your child’s pillow wet in the morning?

Have you noticed your child has difficulty breathing or with a lot of effort?

Does your child easily fatigue after exercising?

Does your child keep their mouth open while watching TV or using the computer?

Does your child demonstrate poor posture while sitting or standing?

Does your child drool during the day?

Does your child eat with their lips open?

Is your child a messy eater?

Does your child easily catch colds?

Does your child have a history of allergies?

Does your child have a history of the following:

Does your child have difficulty pronouncing sounds?

Has your child ever visited an ENT? If so, what for?

Does your child grind or clench their teeth during the day or at night?

Does your child play a musical instrument? If so, which one?

What would you like your child to gain from this therapy?

Email *