Patient Assessment

Many children suffer from undiagnosed sleep disordered breathing resulting in behavioral issues, bed wetting, allergies, and learning difficulties. Please complete the following information to see if your child could benefit from oral sleep modification therapy.  

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* 1. Today's Date

Date / Time

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* 2. Child's First & Last Name

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* 4. Patient DOB (MM/DD/YY)

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* 5. Does your child have any excess spacing or crowding of their teeth?

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* 6. While sleeping, does your child breathe with his/her mouth open?

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* 7. While sleeping, does your child grind his/her teeth?

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* 8. Does your child snore?

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* 9. Is your child able to touch the roof of their mouth with the tip of their tongue?

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* 10. With his/her mouth closed, my child can

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* 11. Check any of the following that currently describes your child...

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* 12. Parent/Guardian First & Last Name

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* 13. Parent/Guardian Phone Number

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* 14. Parent/Guardian Email Address

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* 15. I would like to be contacted for a free consultation if my child is a candidate for improved sleep or habit correction.

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