For Patient:
First Name:    Last Name: 

Dr. Schreiner and Dr. Alizadeh would like you to complete the following questionnaire for your child to help evaluate their current sleep and airway situation which plays a major role in dental development.

Please check if:

While sleeping your child snores more than half the time
While sleeping your child always snores
While sleeping your child snores loudly
While sleeping your child has "heavy" or "loud" breathing
While sleeping your child has trouble breathing or struggles to breath
You have seen your child stop breathing during sleep
Your child tends to breath through their mouth during the day
Your child has a dry mouth when waking in the morning
Your child occasionally wets the bed
Your child wakes-up un-refreshed in the morning
Your child experiences sleepiness during the day
A teacher or supervisor has commented that your child appears sleepy or sluggish during the day
It is hard to wake your child in the morning
Your child wakes up with headaches
Your child has stopped growing at a normal rate
Your is child overweight
Your child does not seem to listen when spoken to directly.
Your child often is easily distracted.
Your child often has difficulty organizing tasks and activities.
Your child fidgets or squirms.
Your child is often "on the go" or acts as if "motor driven."
Your child often interrupts or intrudes.