*Note to Parents/Guardians:

Please answer the following questions about your child's sleep patterns and behaviors. Your responses will help us assess potential sleep-related concerns. (Valid for 2–18 years old)

Does your child always snores? *yesnoI don't know

While sleeping does your child... Snore more than half the time? *yesnoI don't know

While sleeping does your child... Has "heavy" or loud breathing?? *yesnoI don't know

While sleeping does your child... snores loudly? *yesnoI don't know

Does your child... Tend to breathe through the mouth during the day? *yesnoI don't know

Have trouble breathing or struggle to breathe? *yesnoI don't know

Have you ever... Seen your child stop breathing during the night? *yesnoI don't know

Has a dry mouth on waking up in the morning? *yesnoI don't know

Occasionally wet the bed? *yesnoI don't know

Wake up feeling un-refreshed in the morning? *yesnoI don't know

Have a problem with sleepiness during the day? *yesnoI don't know

Is it hard to wake your child up in the morning? *yesnoI don't know

Has a teacher or other supervisor commented that your child appears sleepy during the day? *yesnoI don't know

Does your child wake up with headaches in the morning? *yesnoI don't know

Did your child stop growing at a normal rate at any time since birth? *yesnoI don't know

Is your child overweight? *yesnoI don't know

This child often... Does not seem to listen when spoken to directly *yesnoI don't know

Has difficulty organizing tasks *yesnoI don't know

Is easily distracted by extraneous stimuli *yesnoI don't know

Fidgets with hands or feet or squirms in seat *yesnoI don't know

Is "on the go" or often acts as if "driven by a motor" *yesnoI don't know

Interrupts or intrudes on others (e.g. butts into conversations or games) *yesnoI don't know

Name *

Email Address *

Phone *

Street Address

Apartment, suite, etc

City

Country

Dental Implants ¦ Teeth Straightening

Dental Implants ¦ Teeth Straightening

cosmetic and conservative dentistry

Dubai HealthCare City, Dubai UAE

COSMETIC AND CONSERVATIVE DENTISTRY

we accept all dental insurances

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