Dental Airway Assessment Form
Evaluate key dental airway considerations with this concise assessment.
Patient Age
*
Does the patient snore regularly?
*
Yes
No
Unsure
Mouth breathing during sleep?
*
Yes
No
Occasionally
Observed daytime sleepiness or fatigue?
Yes
No
Sometimes
Airway patency rating (visual or clinical assessment)
*
1
2
3
4
5
Physical findings checklist
High-arched palate
Enlarged tonsils
Tongue scalloping
Retrusive jaw
Other
Mallampati score (visual assessment)
Please Select
Class I
Class II
Class III
Class IV
Clinical observation table
Rows
Normal
Mild
Moderate
Severe
Tonsil size
1
2
3
4
Tongue size
5
6
7
8
Palate shape
9
10
11
12
Additional notes or observations
Submit Assessment
Should be Empty: