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 *

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