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
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