HealthyStart 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 Submit Your request has been sent -- we will be in contact with you shortly. Please make sure ALL fields are filled out correctly.