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574-968-5166
FOR DOCTORS
PATIENT PORTAL
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I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
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I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
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Hawaii
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Massachusetts
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Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
Additional Provider Office (if applicable)
Last Visit
Month
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Doctor Name
Office Phone
Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
Patient Initials
*
Current Symptoms
Reason for this appointment
Pain
Sleep/Airway
Orthodontics
Other:
Please check all symptoms you are currently experiencing:
Back Pain
Difficulty Closing Mouth
Dizziness
Dyskinesia
Ear Congestion
Ear Pain
Ear Stuffiness
Eye Pain
Facial Pain
Headache (inside head)
Headache (outside head)
Jaw Joint Locking
Jaw Joint Noises
Jaw Pain
Limited Ability to Open
Muscle Twitching
Neck Pain
Nerve Pain
Numbness
Pain When Chewing
Shoulder Pain
Sinus Congestion
Throat Pain
Tinnitus (Ringing in Ears)
Vision Problems
Acid Indigestion
Affecting Sleep Partner
Difficulty Falling Asleep
Dry Mouth Upon Waking
Fatigue
Feel Unrefreshed in Morning
Frequent Heavy Snoring
Frequent Tossing & Turning
Kicking/Jerking Legs Repeatedly
Morning Headaches
Morning Hoarseness in Voice
Night Sweats
Nighttime Choking Spells
Nighttime Urination
Repeated Awakening
Short of Breath
Sore Jaw Upon Waking
Swelling in Ankles/Feet
Teeth Crowding
Teeth Grinding
Told I Stop Breathing During Sleep
Unable to Tolerate CPAP
Vivid Dreams
Chief Complaints
List your top 5 chief complaints from the list above starting with your most bothersome symptom
Chief Complaint #1
Back Pain
Difficulty Closing Mouth
Dizziness
Dyskinesia
Ear Congestion
Ear Pain
Ear Stuffiness
Eye Pain
Facial Pain
Headache (inside head)
Headache (outside head)
Jaw Joint Locking
Jaw Joint Noises
Jaw Pain
Limited Ability to Open
Muscle Twitching
Neck Pain
Nerve Pain
Numbness
Pain When Chewing
Shoulder Pain
Sinus Congestion
Throat Pain
Tinnitus (Ringing in Ears)
Vision Problems
Acid Indigestion
Affecting Sleep Partner
Difficulty Falling Asleep
Dry Mouth Upon Waking
Fatigue
Feel Unrefreshed in Morning
Frequent Heavy Snoring
Frequent Tossing & Turning
Kicking/Jerking Legs Repeatedly
Morning Headaches
Morning Hoarseness in Voice
Night Sweats
Nighttime Choking Spells
Nighttime Urination
Repeated Awakening
Short of Breath
Sore Jaw Upon Waking
Swelling in Ankles/Feet
Teeth Crowding
Teeth Grinding
Told I Stop Breathing During Sleep
Unable to Tolerate CPAP
Vivid Dreams
Chief Complaint #2
Back Pain
Difficulty Closing Mouth
Dizziness
Dyskinesia
Ear Congestion
Ear Pain
Ear Stuffiness
Eye Pain
Facial Pain
Headache (inside head)
Headache (outside head)
Jaw Joint Locking
Jaw Joint Noises
Jaw Pain
Limited Ability to Open
Muscle Twitching
Neck Pain
Nerve Pain
Numbness
Pain When Chewing
Shoulder Pain
Sinus Congestion
Throat Pain
Tinnitus (Ringing in Ears)
Vision Problems
Acid Indigestion
Affecting Sleep Partner
Difficulty Falling Asleep
Dry Mouth Upon Waking
Fatigue
Feel Unrefreshed in Morning
Frequent Heavy Snoring
Frequent Tossing & Turning
Kicking/Jerking Legs Repeatedly
Morning Headaches
Morning Hoarseness in Voice
Night Sweats
Nighttime Choking Spells
Nighttime Urination
Repeated Awakening
Short of Breath
Sore Jaw Upon Waking
Swelling in Ankles/Feet
Teeth Crowding
Teeth Grinding
Told I Stop Breathing During Sleep
Unable to Tolerate CPAP
Vivid Dreams
Chief Complaint #3
Back Pain
Difficulty Closing Mouth
Dizziness
Dyskinesia
Ear Congestion
Ear Pain
Ear Stuffiness
Eye Pain
Facial Pain
Headache (inside head)
Headache (outside head)
Jaw Joint Locking
Jaw Joint Noises
Jaw Pain
Limited Ability to Open
Muscle Twitching
Neck Pain
Nerve Pain
Numbness
Pain When Chewing
Shoulder Pain
Sinus Congestion
Throat Pain
Tinnitus (Ringing in Ears)
Vision Problems
Acid Indigestion
Affecting Sleep Partner
Difficulty Falling Asleep
Dry Mouth Upon Waking
Fatigue
Feel Unrefreshed in Morning
Frequent Heavy Snoring
Frequent Tossing & Turning
Kicking/Jerking Legs Repeatedly
Morning Headaches
Morning Hoarseness in Voice
Night Sweats
Nighttime Choking Spells
Nighttime Urination
Repeated Awakening
Short of Breath
Sore Jaw Upon Waking
Swelling in Ankles/Feet
Teeth Crowding
Teeth Grinding
Told I Stop Breathing During Sleep
Unable to Tolerate CPAP
Vivid Dreams
Chief Complaint #4
Back Pain
Difficulty Closing Mouth
Dizziness
Dyskinesia
Ear Congestion
Ear Pain
Ear Stuffiness
Eye Pain
Facial Pain
Headache (inside head)
Headache (outside head)
Jaw Joint Locking
Jaw Joint Noises
Jaw Pain
Limited Ability to Open
Muscle Twitching
Neck Pain
Nerve Pain
Numbness
Pain When Chewing
Shoulder Pain
Sinus Congestion
Throat Pain
Tinnitus (Ringing in Ears)
Vision Problems
Acid Indigestion
Affecting Sleep Partner
Difficulty Falling Asleep
Dry Mouth Upon Waking
Fatigue
Feel Unrefreshed in Morning
Frequent Heavy Snoring
Frequent Tossing & Turning
Kicking/Jerking Legs Repeatedly
Morning Headaches
Morning Hoarseness in Voice
Night Sweats
Nighttime Choking Spells
Nighttime Urination
Repeated Awakening
Short of Breath
Sore Jaw Upon Waking
Swelling in Ankles/Feet
Teeth Crowding
Teeth Grinding
Told I Stop Breathing During Sleep
Unable to Tolerate CPAP
Vivid Dreams
Chief Complaint #5
Back Pain
Difficulty Closing Mouth
Dizziness
Dyskinesia
Ear Congestion
Ear Pain
Ear Stuffiness
Eye Pain
Facial Pain
Headache (inside head)
Headache (outside head)
Jaw Joint Locking
Jaw Joint Noises
Jaw Pain
Limited Ability to Open
Muscle Twitching
Neck Pain
Nerve Pain
Numbness
Pain When Chewing
Shoulder Pain
Sinus Congestion
Throat Pain
Tinnitus (Ringing in Ears)
Vision Problems
Acid Indigestion
Affecting Sleep Partner
Difficulty Falling Asleep
Dry Mouth Upon Waking
Fatigue
Feel Unrefreshed in Morning
Frequent Heavy Snoring
Frequent Tossing & Turning
Kicking/Jerking Legs Repeatedly
Morning Headaches
Morning Hoarseness in Voice
Night Sweats
Nighttime Choking Spells
Nighttime Urination
Repeated Awakening
Short of Breath
Sore Jaw Upon Waking
Swelling in Ankles/Feet
Teeth Crowding
Teeth Grinding
Told I Stop Breathing During Sleep
Unable to Tolerate CPAP
Vivid Dreams
What is your level of head, neck, and facial pain?
0 = no pain to 10 = worst possible pain
Currently:
At its best:
At its worst:
What results are you seeking from treatment?
Please check any dental symptoms that you are currently experiencing:
Changes in Bite
Dental Changes
Teeth Crowding
Teeth Sensitivity
Teeth Spacing
None
Any symptoms not listed above?
In which position do you sleep?
Back
Side
Stomach
Varies
Where do you sleep?
Bed
Couch
Chair
Other
Do you have a bed partner?
Yes
No
Is it easy for you to fall asleep?
Yes
No
How many times do you wake during the night?
Do you feel rested upon waking?
Yes
No
Has anyone ever told you that you stop breathing during sleep?
Yes
No
Have you ever had a sleep study?
Yes
No
If yes:
Date:
Location:
Patient Initials
*
Medications
Please list all medications you are currently taking and the reason you are taking them. Include prescription, over the counter, vitamins, herbs, etc. (Please attach an additional sheet if necessary)
Medication
Dosage
Reason for Taking
Upload Separate Document with Medications Not Listed Above
Max. file size: 50 MB.
Previous treatments/medications for the condition we are evaluating:
Treatment/Medication
Doctor/Provider
Approximate Date of Treatment
TMJ & Sleep Therapy Centre has my permission to obtain my complete medication history, including electronic prescription submission
Allergies
Please check any and all medications or substances that have caused an allergic reaction:
Anesthetics
Antibiotics
Aspirin
Barbiturates
Codeine
Iodine
Latex
Metals
Penicillin
Plastic
Sedatives
Sulfa
Other
Medical History
Have you had prior orthodontic treatment?
Yes
No
Have you had sustained injury to:
Head
Face
Neck
Teeth
Other
If you experienced an injury listed above, please provide a brief explanation
Please indicate if you have had any of the following:
General Anesthesia
Adenoids Removed
Tonsils Removed
Jaw Joint Surgery
Orthognathic Surgery
Oral Surgery
Removal of Wisdom Teeth
Nasal Surgery
Other Surgeries
Do you have trouble breathing through your nose?
Yes
No
Are you currently pregnant?
Yes
No
Do you drink 4 or more cups of coffee per day?
Yes
No
Do you smoke tobacco?
Yes
No
Do you consume alcohol?
Yes
No
If yes:
Habitually
Socially
Do you take any sedatives/medications/supplements to help yourself fall asleep at night?
Yes
No
If yes, what?
Patient Initials
*
Medical History, Continued
Have you ever experienced: (Optional - check applicable)
Physical Abuse
Verbal Abuse
Emotional Abuse
Sexual Abuse
None
If yes, please explain (Optional)
Do you have or have you experienced any of the following?
AIDS/HIV
Anemia
Anxiety
Asthma
Birth Defects
Bleeding Easily
Bruising Easily
Cancer
Chronic Fatigue
Cold Hands and Feet
Depression
Diabetes
Difficulty Breathing at Night
Difficulty Concentrating
Dizziness
Eating Disorder
Ehlers-Danlos Syndrome (EDS)
Emphysema
Epilepsy
Excessive Thirst
Fainting
Fibromyalgia
Fluid Retention
Frequent Awakening at Night
Frequent Colds/Flus
Frequent Cough
Frequent Ear Infections
Frequent Sore Throat
Gastroesophageal Reflux (GERD)
Glaucoma
Hay Fever
Hearing Impairment
Heart Disorder/Heart Attack
Heart Murmur
Heart Pacemaker
Heart Palpitations
Heart Valve Replacement
Hemophilia
Hepatitis
High Blood Pressure
History of Substance Abuse
Huntington’s Disease
Hypoglycemia
Insomnia
Intestinal Disorder
Irregular Heartbeat
Kidney Disease
Leukemia
Liver Disease
Low Blood Pressure
Memory Loss
Meniere’s Disease
Migraines
Mitral Valve Prolapse
Muscle Aches
Muscular Dystrophy
Muscle Fatigue
Muscle Spasms
Muscle Tremors
Multiple Sclerosis
Nervous System Disorder
Neuralgia
Osteoarthritis
Osteoporosis
Ovarian Cyst
Parkinson’s Disease
Poor Circulation
Postural Orthostatic Tachycardia Syndrome (POTS)
Psychiatric Care
Recent Weight Gain
Recent Weight Loss
Rheumatoid Arthritis
Rheumatoid Fever
Scarlet Fever
Seizures
Shortness of Breath
Significant Daytime Drowsiness
Sinus Problems
Skin Disorder
Slow Healing Sores
Sleep Apnea
Speech Difficulties
Stroke
Swollen, Stiff, or Painful Joints
Thyroid Problem
Tired Muscles
Tuberculosis
Urinary Tract Disorder
Does your family have a history of similar conditions, symptoms, or diseases?
Yes
No
If yes, who?
Have you been prescribed a CPAP?
Yes
No
Do you use it as prescribed?
Yes
No
Have you had a previous oral appliance, mouthguard, splint, retainer?
Yes
No
Do you use it as prescribed?
Yes
No
How many hours of sleep, on average, do you get per night?
How many hours of sleep, on average, during the day?
Do you ever cough, gasp, or snort upon waking?
Yes
No
Patient Initials
*
Currently Experiencing
Are you currently experiencing head pain?
Yes
No
If yes, please indicate all that apply:
Temple Area (Temporal)
Back of Head (Occipital)
Forehead (Frontal)
Top of Head (Parietal)
General Head Pain
Where is your temporal pain located?
Left
Right
Bilateral
How long have you experienced temporal pain?
Recent
Chronic (over 6 mo.)
What is the severity of your temporal pain?
Mild
Moderate
Severe
What is the duration of your temporal pain?
Minutes
Hours
Days
What is the frequency of your temporal pain?
Occasional
Frequent
Constant
Where is your occipital pain located?
Left
Right
Bilateral
How long have you experienced occipital pain?
Recent
Chronic (over 6 mo.)
What is the severity of your occipital pain?
Mild
Moderate
Severe
What is the duration of your occipital pain?
Minutes
Hours
Days
What is the frequency of your occipital pain?
Occasional
Frequent
Constant
Where is your frontal pain located?
Left
Right
Bilateral
How long have you experienced frontal pain?
Recent
Chronic (over 6 mo.)
What is the severity of your frontal pain?
Mild
Moderate
Severe
What is the duration of your frontal pain?
Minutes
Hours
Days
What is the frequency of your frontal pain?
Occasional
Frequent
Constant
Where is your parietal pain located?
Left
Right
Bilateral
How long have you experienced parietal pain?
Recent
Chronic (over 6 mo.)
What is the severity of your parietal pain?
Mild
Moderate
Severe
What is the duration of your parietal pain?
Minutes
Hours
Days
What is the frequency of your parietal pain?
Occasional
Frequent
Constant
Where is your general head pain located?
Left
Right
Bilateral
How long have you experienced general head pain?
Recent
Chronic (over 6 mo.)
What is the severity of your general head pain?
Mild
Moderate
Severe
What is the duration of your general head pain?
Minutes
Hours
Days
What is the frequency of your general head pain?
Occasional
Frequent
Constant
Are you currently experiencing jaw conditions?
If yes, please indicate all that apply:
Yes
No
Jaw pain with opening
Left
Right
Jaw pain when chewing
Left
Right
Jaw pain at rest
Left
Right
Jaw sounds with opening
Left
Right
Jaw sounds when chewing
Left
Right
Jaw sounds at rest
Left
Right
Please indicate if you have had any of the following:
Jaw Locks Closed
Jaw Locks Open
Daytime Teeth Clenching/Grinding
Nighttime Clenching/Grinding
Blurred Vision
Double Vision
Pain/Pressure behind eyes
Extreme Sensitivity to light
Wear Glasses or Contact Lenses
Are you currently experiencing any ear related conditions?
If yes, please indicate all that apply:
Yes
No
Ear Congestion
Left
Right
Ear Pain
Left
Right
Hearing Loss
Left
Right
Itchiness or Stuffiness in Ears
Left
Right
Pain Behind the Ear
Left
Right
Pain in Front of the Ear
Left
Right
Recurrent Ear Infections
Left
Right
Ringing in the Ear
Left
Right
Please indicate your areas of pain by identifying the applicable letters from the body and head diagrams above and labeling with the appropriate numbers 1-3
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
AA
BB
CC
DD
EE
FF
GG
HH
II
JJ
KK
LL
MM
NN
OO
Patient Initials
*
Please indicate if you have had any of the following:
Chronic Sore Throat
Difficulty Swallowing
Swollen Gland
Thyroid Enlargement
Tightness in Throat
Constant Feeling of Foreign Object in Throat
Limited Movement of Neck
Neck Pain
Numbness in hands/fingers
Swelling in the neck
Shoulder Pain
Shoulder Stiffness
Tingling in hands or fingers
Lower Back Pain
Upper Back Pain
Middle Back Pain
Scoliosis
Sciatica
Chronic Sinusitis
Broken Teeth
Dry Mouth
Frequent Biting of the Cheek
Burning Tongue Sensation
Symptom History
On what date, or approximate date, did your condition/symptoms first occur?
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Can you relate your pain/condition to a motor vehicle accident or traumatic injury?
Yes
No
If yes, please explain:
Does any family member have a sleep breathing disorder or Obstructive Sleep Apnea?
Yes
No
If yes, who?
Does any family member have the same or a similar problem?
Yes
No
If yes, please explain:
Additional Information
Is there anything else you would like us to know?
Patient Initials
*
PHQ-9
Complete this page if you are 12 years of age or older
1. Over the last 2 weeks, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in doing things
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
b. Feeling down, depressed, or hopeless
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
c. Trouble falling/staying asleep, sleeping too much
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
d. Feeling tired or having little energy
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
e. Poor appetite or overeating
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
f. Feeling bad about yourself or that your are a failure or have let yourself or your family down
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
g. Trouble concentrating on things, such as reading the newspaper or watching television
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
h. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
i. Thoughts that you would be better off dead or of hurting yourself in some way
1 - Not at all
2 - Several days
3 - More than half the days
4 - Nearly every day
Count the total number of answers you listed for the questions above
0 - Not at all
Please enter a number less than or equal to
7
.
1 - Several days
Please enter a number less than or equal to
7
.
2 - More than half the days
Please enter a number less than or equal to
7
.
3 - Nearly every day
Please enter a number less than or equal to
7
.
Total
2. If you checked off any problem on this questionnaire so far...
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Patient Initials
*
GAD-7
Complete this page if you are 12 years of age or older
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
2. Not being able to stop or control worrying
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
3. Worrying too much about different things
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
4. Trouble relaxing
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
5. Being so restless that it is hard to sit still
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
6. Becoming easily annoyed or irritable
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
7. Feeling afraid, as if something awful might happen
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Count the total number of answers you listed for the questions above
0 - Not at all
Please enter a number less than or equal to
7
.
1 - Several days
Please enter a number less than or equal to
7
.
2 - More than half the days
Please enter a number less than or equal to
7
.
3 - Nearly every day
Please enter a number less than or equal to
7
.
Total
If you have checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
Not at all
Somewhat difficult
Very difficult
Extremely difficult
Patient Initials
*
Emergency Contact Information
In case of an emergency, please contact:
Name
Phone
Relationship
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
The person(s) listed have my approval to access my information:
Mark an "X" in the appropriate Information Box(es)
Name
Relationship
Medical Information
Financial Information
Signature
Acknowledgement
*
I acknowledge that I have been offered a copy of the Office Privacy Notice and I am familiar with my rights as a patient of Dr. Klauer and TMJ & Sleep Therapy Centre. I understand this practice is Fee for Service Out-of-Network and regardless of my insurance coverage, I am responsible for any charges incurred at the time of my visit.
Signature
*
My signature certifies that the information listed on this form is accurate and complete to the best of my knowledge
Date
*
MM slash DD slash YYYY
Parent/Guardian Signature
My signature above certifies that the information listed on this form is accurate and complete to the best of my knowledge.
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
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BMI Conversion Chart
Weight (in pounds)
*
Height (feet)
*
Height (inches)
*
Your BMI
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