Parent First Name *

Parent Last Name *

Parent Email *

Parent Phone *

Child First Name

Child Last Name

Child's Birth Date

While sleeping, does your child...

have trouble breathing or struggle to breath?

Yes

No

Don't Know

stop breathing during the night or gasp for air?

Yes

No

Don't Know

have 'heavy' or loud breathing?

Yes

No

Don't Know

snore regularly?

Yes

No

Don't Know

appear to be a restless sleeper

Yes

No

Don't Know

have nightmares?

Yes

No

Don't Know

grind their teeth?

Yes

No

Don't Know

Upon waking up, does your child...

have a dry mouth in the morning or chapped, dry lips?

Yes

No

Don't Know

tend to breathe through the mouth during the day?

Yes

No

Don't Know

wake up feeling un-refreshed in the morning?

Yes

No

Don't Know

have a problem with sleepiness during the day?

Yes

No

Don't Know

have trouble getting going in the morning?

Yes

No

Don't Know

Have you noticed that your child...

not seem to listen when directly spoken to?

Yes

No

Don't Know

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