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FACE FORWARD FNQ

NEW PATIENT INFORMATION FORM

Welcome to Face Forward – FNQ Orofacial Collaboration is a specialist clinic providing team-based care for jaw pain, facial discomfort, breathing and airway concerns, and oral function issues. Our care is led by three sisters — an orthodontist, a GP, and a speech pathologist, who work closely with other professionals to provide holistic, coordinated care tailored to your unique needs.

For Adults, whether you’re experiencing jaw discomfort, muscle tension, difficulties with breathing, swallowing, or speech, we aim to identify the root cause and support you with a plan that works, functionally and practically.

For children, we focus on early identification and support of functional issues such as mouth breathing, speech clarity, swallowing patterns, tongue posture, and jaw development, helping to set strong foundations for long‑term health and development.

Client & Contact Details

Patient first name

Patient surname

Date of birth

Age

Home phone

Mobile phone

Email Address

Home address

Mailing Address (if different)

Parent / Carer Completing this form (if applicable)

Phone

Information on relationship to patient

Funding & Insurance Details

Face Forward is a private billing clinic. A non-refundable deposit of 50% is required to secure your booking. Your appointment is not confirmed until payment has been received. The remaining balance is due and payable at your initial appointment.

Appointments are set aside especially for you (or your child). If you cannot attend please let us know as early as possible - ideally with 48 hours notice. Cancellations made more than 48 hours in advance may transfer the deposit to a new date (subject to availability). Cancellations within 24 hours or failure to attend will result in forfeiture of the deposit.

Health Fund (if you do not have private health, please write uninsured)

Education / Employment

School / Year Level / Occupation

Reason for Referral / Main Concerns

Additional InformationPlease describe the problem: When did it begin? Has the problem changed since first noticed? Is the problem consistent or does it vary? How do you react or respond to the problem, Does it bother you and what do you do about it?

Where else have you been for the problem?What did they suggest? Did it help?

How have you tried to help the problem?

Why did you decide to come for an evaluation?

Medical & Developmental History

Medical Conditions or Diagnoses

Surgeries, Hospitalisations, or Significant illnesses

HearingIf concerns please provide information below

VisionPlease provide additional information below

Additional information on hearing and/or vision

Medications

Allergies

Pregnancy & Birth History

Developmental MilestonesPlease provide additional information if milestones were delayed below

Movement and Communication Milestonese.g. Crawl 8mths, Walk 14mths, Talk 14mths, 2 Words around 2yrs

Any learning difficulties or additional support required

YesNo

Details of supports

Language/s spoken at home

Interests / Strengths

Feeding/Eating and Oral Habits

Feeding/Eating/Swallowing Difficulties

YesNo

Feeding difficulties (past or present) difficulties with chewing steak, difficulties with managing saliva, difficulties with mixed consistencies

Infant Feeding

BreastfedBottle fedMixed

Thumb / Finger Sucking

YesNoCurrently

Thumb / Finger sucking until

Dummy Use

YesNoCurrently

Dummy use until

Additional Information (if required)Please provide any additional information that you feel will assist your speech pathologist

Have you ever:

YesNo

been told that you stop breathing / or seen your child stop breathing during the night?

YesNo

Consent & Privacy Acknowledgment

I consent to the use of AI medical scribe. We utilise a note taking tool called Heidi to accurately and effectively capture the details of our discussions and the outcome of our appointments. Heidi ensures that we can focus more on our conversations and less on manual note taking, enhancing the quality of care that you receive,

Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi's use is aimed solely at improving your healthcare experience.

I confirm that above information I have provided is true, complete and accurate. I understand that the information collected in this form is confidential and used solely for the purpose of providing assessment and therapy. *

Signature (Client / Parent / Guardian) *

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Date *

Clinical Use Only

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