Step 1: Take our Children’s Sleep

and Breathing Questionnaire

First Name *

Last Name *

Email *

Phone *

Patient's Name *

Patient's Age *

Does your child wake up frequently at night or get really tired during the day? *

Yes

No

Does your child snore and/or can you hear them breathe? *

Yes

No

Is your child hyperactive and/or do they have difficulty focusing? *

Yes

No

Does your child grind their teeth? *

Yes

No

Does your child have crooked teeth? *

Yes

No