SLEEP SURVEY

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

Date

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* 2. Child's First & Last Name

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* 3. Patient Gender

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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?

Yes, crowding

Yes, spacing

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

yes

sometimes

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

yes

sometimes

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* 8. Does your child snore?

yes

sometimes

Other (please specify)

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

Yes

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

breathe normally through his/her nose

has difficulty breathing through his/her nose

cannot breathe through his/her nose

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

hyperactive

talks in sleep

tosses & turns at night/restless

stops breathing while sleeping

sleep walks

allergic symptoms

excessive sweating while asleep

labored, difficult, loud breathing at night

interrupted snoring where breathing stops

stoppage of breathing more than 2 times per hour

frequent morning headaches

difficulty concentrating at school

falls asleep watching TV

wakes up at night

frequent throat infections

wets the bed

speech problems

mouth breathes during the day

feels sleepy and/or irritable during the day

has a hard time listening and often interrupts

fidgets with hands or does not sit quietly

uses a pacifier

sucks thumb

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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.

Yes