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  • 2322 196th St. SW, Suite 201 Lynnwood, WA 98036 | Call Us Today! 206-316-8286

Child Patient Form

New Patient - Child Form

"*" indicates required fields

Home Address*

Please explain your reason for seeking treatment so that we may best meet your needs

Medical History

Has your child experienced any health problems?*
Any major change in your child's health recently?*
Is your child currently under a physician's care?*
Is your child currently taking and medications?*
Is your child currently allergic to any medications?*
Have your child received a blood transfusion?*
Have your child's tonsils or adenoids been removed?*
ADD/Behavior Issues*

Has your child experienced any of the following conditions?

Has your child experienced any of the following conditions?*

Growth Information for Patients UNDER 16 Years of Age

Because growth can be an important factor in orthodontic treatment planning, your answers to the following questions are needed to aid our selection of treatment alternatives:
Has your child reached puberty?*
Girls - Has she started menstruations?
Boys - Has his voice changed?
Do you feel growth is completed?*

Dental History

Is there any unfinished care to be completed with child's dentist?*
Is your child frightened about dental treatment?*
Has your child has an unpleasant experience at a dental office?*
Has your child has and face dental injuries?*
Is there a history of thumb sucking?*
Does your child play and instrument?*
Has your child consulted and orthodontist previously?*
Have teeth (either primary or permanent) been removed?*
Has your child had any previous otherdontic treatment?*
Are you satisfied with prior treatment?*

Does your child have a history of any of the following?

Does your child have a history of any of the following?*

Pediatric Sleep Questionnaire

Patients under 18 years of age
Please answer on behalf of your child for the past month

While sleeping, does your child...

Snore more than half the time?*
Always Snore?*
Snore Loudly?*
Have trouble breathing, or struggle to breathe?*
Have "heavy" or loud breathing?*
Have you ever seen your child stop breathing during the night?*

Does your child...

Tend to breathe through the mouth during the day?*
Have a dry mouth on making up in the morning?*
Wake up feeling unrefreshed in the morning?*
Have a problem with sleepiness during the day?*
Has a teacher commented that your child appears sleepy during the day?*
Did your child stop growing at a normal rate at any time since birth?*
Is your child overweight?*

My child often...

Does not seem to listen when spoken to directly?*
Has difficulty organizing tasks and activities?*
Is easily distracted by extraneous stimuli?*
Fidgets with hands, feed, and/or squirms in seat?*
Is 'on the go' or often acts as if 'driven by a motor'?*
Interrupts or intrudes on others?*