sleep-questionnaire
 

Please, fill out the information below and we will contact you shortly.

Does your child sleep with their mouth open?

All the time
Some of the time
Never

Does your child suffer from any of these symptoms

Difficulty listening
Attention deficit
Frequent throat infections speech problems
Mouth breathing
Hyperactivity
Allergies
None of the above

Does your child suffer from any of these night time issues?

Snoring
Teeth grinding
Bedwetting
Sweating while asleep
Restless sleep
Wakes often or talks in their sleep
None of the above

Does your child have crooked teeth?

Yes
Yes, but they are receiving treatment
No

Does your child’s chin seem too far back or the upper teeth too far forward?

Yes
No
Your request has been sent -- we will be in contact with you shortly.
Please make sure ALL fields are filled out correctly.