Tao Dental Care
www.dentaltao.com, 10011 N. Foothill Blvd #109, Cupertino, CA 95014, firstname.lastname@example.org, (408) 737-2988
1. Does your child have trouble going to bed or falling asleep?
2. Awaken during the night and have trouble returning to sleep?
3. Does he/she tend to breathe through their mouth during the day or during sleep?
4. Have dry mouth or bad breath upon waking in the morning?
5. Have you noticed any of the following while your child is sleeping (Check all that apply):
Snoring, heavy or loud breathing
Break or pause in breathing
Gasp, choke, or struggle to breathe
Restless or agitated sleep
Abnormal head posture (hyper-extension, etc.)
6. Have you noticed any of the following during the day (Check all that apply):
Wakes with headaches
Groggy, tired or "out of it"
7. Child Often (check all that apply):
Easily distracted by extraneous stimuli
Has difficulty organizing tasks
Interrupts or intrudes on others
Fidgets with hands or feet or squirms in seat
8. Is your child frequently sick, have history of sore throat, ear infections, or sinus infections?
9. Stop growing at a normal rate at any time since birth? Overweight?
10. Habits such as: pacifier/ thumb sucking/ lip biting/ other?
Should be Empty: