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Sleep Disordered Breathing Questionnaire for Children
This is an initial screening form to determine whether or not your child is eligible for a Healthy Start Sleep Disordered Breathing consult.
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* Indicates required question
Email
*
Your email
First Name (Parent)
*
Your answer
Last Name (Parent)
*
Your answer
Age of child
*
Your answer
Are the baby teeth in line without spaces or with minor spacing?
Yes
No
Clear selection
Does your child exhibit any ONE of these symptoms...
Teeth Grinding
Bedwetting
ADD / ADHD behavior
Crooked Teeth
Dark circles under the eyes
Snoring
Is your child a restless sleeper?
Yes
No
Clear selection
Does your child wake up frequently during the night?
Yes
No
Clear selection
Does your child breathe through their mouth during daytime or during sleep?
Yes
No
Clear selection
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