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Please indicate to what degree your child exhibits any of the following symptoms on a scale of 0-5, 0 being not present at all.
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Snore at all?
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Snore only infrequently (once/week)
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Snore fairly often?
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Snore habitually (5-7 nights/week)
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have labored, loud, difficult breathing at night
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Have interrupted snoring where breathing stops for 4 or more seconds
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Have stoppage of breathing more than 2 times per hour during sleep
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hyperactivity
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mouth breathes during the day
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mouth breathes while sleeping
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frequent headaches in the morning
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allergy symptoms (nasal congestion)
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excessive sweating while sleeping
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talks in sleep
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poor ability in school
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falls asleep watching TV
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wakes up at night
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attention deficit
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restless sleep
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Grinds teeth
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frequent throat infections
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feels sleepy and/or irritable during the day
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have a hard time listening and often interrupts
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fidgets with hands or does not sit quietly
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ever wets the bed
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bluish color at night or during the day
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Speech problems* if yes, continue with speech questions #28-35
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Is it difficult to understand your child's speech?
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Difficult to understand over the phone?
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nasal speech?
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speech sounds abnormal?
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others have difficulty understanding speech
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Gets frustrated when people can't understand speech?
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sometimes omits consonants
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Uses M, N, NG instead of P, F, V, S, Z
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Hoarseness
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Lisp
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Any speech therapy? how long?
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Does your child frequently have chapped lips?
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Would you say your child is a "picky eater"?
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Does your child have a hard time waking in the morning?
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Does your child have a hard time falling asleep?
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Have a strong gag reflex?
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Have asthma?
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Have dietary restrictions? Please explain.
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Take medicine for asthma?
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Does your child have frequent nightmares?
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Does your child toss and turn at night (sheets are messy in the morning)?
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Does your child take a long time to complete meals?
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Does your child have noisy breathing during the day?
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Does your child lean the cheek on the hand frequently?
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During Infancy
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Did your child breastfeed at all?
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If so, for how long?
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Did your child bottle feed? For how long?
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New Short Text Field
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Did your child use a pacifier?
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Does your child currently use a pacifier?
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If yes, until what age?
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Did your child have a lip or tongue tie revision as an infant?
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Does your child suck on fingers or thumb now or in the past?
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Did your child have frequent ear infections?
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Did your child have ear tubes placed?
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When introduced to solids, did your child get puree or solid food?
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Was your child early to get teeth?
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Was your child late to get teeth?
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Parent History
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Do you have crowded teeth?
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Did you ever have braces?
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Did you ever have teeth removed for braces?
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Did you ever wear headgear?
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