Central Office
Child Assessment Sheet
Personal Information
Patient Name*
Date of Birth*
Medical Issues
Medications Taking
Allergies
Previous clip or release of tongue
Has your child experienced any of the following issues? Please check or elaborate as needed.
Speech
Frustration with communication
Difficult to understand by parents
Difficult to understand by outsiders
% Percent of time you understand your child
Difficulty speaking fast
Difficulty getting words out (groping for words)
Trouble with sounds (which?)
Speech delay (when?)
Stuttering
Speech harder to understand in long sentences
Speech therapy (how long)
Mumbling or speaking softly
"Baby Talks" or uses baby voice
Feeding
Frustration when eating
Difficulty transitioning to solid foods
Slow eater (doesn’t finish meals)
Small appetite / Trouble gaining weight
Grazes on food throughout the day
Packing food in cheeks like a chipmunk
Picky eater/ with textures (which?)
Choking or gagging on food
Spits out food
Won’t try new foods
Other:
Nursing or Bottle-Feeding Issues as a baby
Painful nursing or shallow latch
Poor weight gain
Reflux or spitting up
Gassy (tooted a lot) as baby
Milk leaked out of mouth / messy eater
Poor milk supply
Nipple shield needed for nursing
Clicking or smacking noise when eating
Cried a lot / colic as baby
Other:
Sleep Issues
Sleeps in strange positions
Sleeps restlessly (moves a lot)
Wakes easily or often
Wets the bed
Wakes up tired and not refreshed
Grinds teeth while sleeping
Sleeps with mouth open
Snores while sleeping (how often)
Gasps for air or stops breathing (sleep apnea)
Other related issues
Neck or shoulder pain or tension
TMJ Pain, clicking, or popping
Headaches or migraines
Strong gag reflex
Prolonged thumb sucking / pacifier use
Mouth open /mouth breathing during the day
Tonsils or adenoids removed previously
Ear tubes previously / lots of ear infections
Reflux (medicated or not)
Hyperactivity / Inattention
Constipation
Lip-Tie Issue
Difficult or fights to brush top teeth
Top teeth don’t show when smiling
Gap between two front teeth
Cavities on front teeth
Trouble eating from a spoon/ flips spoon over
Trouble with B,P,M or W sounds
Any Other Issues or Concerns?
Who referred you to us?
Doctor's Signature*
