Parent's Full Name
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Date
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Email
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Phone
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Please Answer The Following Questions By Checking The Box If YES
While sleeping, does your child snore more than half the time?
While sleeping, does your child always snore?
While sleeping, does your child snore loudly?
While sleeping, does your child have “heavy” or loud breathing?
While sleeping, does your child have trouble breathing, or struggle to breathe?
Have you even seen your child stop breathing during the night?
Does your child occasionally wet the bed, sleepwalk, or have night terrors (circle any)?
Does your child tend to breathe through the mouth during the day?
Does your child have a dry mouth on waking in the morning?
Does your child wake up unrefreshed in the morning?
Does your child wake up with headaches in the morning?
Is it hard to wake up your child in the morning?
Does your child have a problem with sleepiness during the day?
Has a teacher or supervisor commented - your child appears sleepy during the day?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?
Your child does not seem to listen when spoken to directly
Your child often has difficulty organizing tasks and activities
Your child often is easily distracted by extraneous stimuli
Your child often fidgets with hands or feet, or squirms in seat
Your child often is “on the go” or often acts as if “driven by a motor”
Your child often interrupts or intrudes on others (butts in conversations or games)
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