CommentsThis field is for validation purposes and should be left unchanged.Date* MM slash DD slash YYYY Patient Name*Age*Gender*Person Filling Out Form*Please rate the following based on the choices given:Snoring* Never Rarely Often Always Labored/difficult/loud night breathing* Never Rarely Often Always Gasping for air while sleeping* Never Rarely Often Always Mouth breaths while sleeping* Never Rarely Often Always Mouth breaths during day* Never Rarely Often Always Restless sleep* Never Rarely Often Always Grinds teeth while sleeping* Never Rarely Often Always Talks in sleep* Never Rarely Often Always Excesive sweating while sleeping* Never Rarely Often Always Wakes up at night* Never Rarely Often Always Wets the bed (currently)* Never Rarely Often Always History of bed wetting* Never Rarely Often Always Sleepy/Irritable during day* Never Rarely Often Always Headaches* Never Rarely Often Always Frequent throat infections* Never Rarely Often Always Seasonal allergies* Never Rarely Often Always Current or history of ear infections* Never Rarely Often Always Difficulty listening/often interrupts* Never Rarely Often Always Hyperactive* Never Rarely Often Always ADD/ADHD* Never Rarely Often Always Sensory issues* Never Rarely Often Always Speech issues* Never Rarely Often Always Avoidance toward food or certain types* Never Rarely Often Always Trouble Focusing* Never Rarely Often Always Any history of the following:Tooth Extraction* Yes No Cavities* Yes No Dental Trauma* Yes No Medications* Yes No Breast Feeding* Yes No Pacifier/Finger or Thumb Sucking* Yes No Bottle Fed* Yes No
