Snoring
*
No Occurrence
Occurs Rarely
Occurs 2-4 Times Per Week
Occurs 5-7 Times Per Week
Snoring where breathing stops
*
No Occurances
Occurs Rarely
Occurs 2-4 Times Per Week
Occurs 5+ Times Per Week
Labored, difficult or loud breathing at night
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Gasping for air while sleeping
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Mouth breathes while sleeping
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Mouth breathes during day
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Restless sleep
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Grinds teeth while sleeping
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Talks in sleep
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Excessive sweating while sleeping
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Wakes up at night
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
History of bed wetting
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Feels sleepy and/or irritable during the day
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Seasonal allergies
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Trouble focusing
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
Difficulty listening/ often interrupts
*
No Occurrence
Occurs Rarely
Occurs 2 to 4 times per week
Occurs 5 to 7 times per week
ADD/ADHD
*
Yes
No
Struggles in school;
*
Yes
No
Speech issues
*
Yes
No
Full Name
*
Email
*
Phone
*