Have you ever seen your child snore?
Yes
No
Have you ever ever seen your child gasp, choke, or stop breathing when sleeping?
Yes
No
Ever catch your child nodding off when they'd rather stay awake?
Yes
No
Does your child often wake up feeling refreshed?
Yes
No
Does your child breathe through their mouth or nose while sleeping?
Mouth
Nose
Does your child breathe through their mouth during the day?
Yes
No
Does your child grind or clinch your teeth while sleeping?
Yes
No
Does your child talk in their sleep?
Yes
No
Does your child sweat a lot while sleeping?
Yes
No
Does your child wake up at night often?
Yes
No
Sometimes
Does your child have seasonal alergies?
Yes
No
Does your child have trouble focusing?
Yes
No
Has your child been diagnoised with ADD/ADHD?
Yes
No
Does your child seem sleepy or irritable during the day?
Yes
No
Does your child struggle in school?
Yes
No
Does your child have any speech issues?
Yes
No
Full Name
*
Email
*
Phone
*