Are the teeth crowded, or is there a lack of space between teeth? *

Yes

No

Is there frequent breathing through the mouth during the day or while asleep? *

Yes

No

Is there frequent tossing, turning, or restless movement during sleep? *

Yes

No

Is there significant daytime fatigue or difficulty concentrating? *

Yes

No

Are the edges of the teeth worn down, flat, or chipped? *

Yes

No

Is snoring or heavy breathing present during sleep? *

Yes

No

Full Name *

Phone *

Email *