ADULT QUESTIONNAIRE

  1. Do you sleep completely through the night?

  2. How many times do you wake up through the night on average?

  3. If you wake up at any point in the night, is it easy for you to fall right back asleep?

  4. Do you wake up feeling refreshed?

  5. Do you wake up feeling fatigued?

  6. Do you know if you clench or grind your teeth during the night?

  7. Do you notice clenching or grinding during the day?

  8. Do you have morning tension or migraine headaches? How often?

  9. Do you ever wake up with facial muscle soreness or feel any soreness come on through the day?

  10. Do you ever notice clicking, popping or pain in your jaw joints?

  11. Do you snore or have you been told you snore or make any noise while sleeping?

  12. Have you noticed or been told you stop or pause your breathing while sleeping?

  13. Have you ever woken yourself up choking or coughing?

  14. Do you snore or have you been told you snore or make any noise while sleeping?

  15. Do you ever take sleep aids before going to bed?

  16. Do you know if you have high blood pressure?

  17. Have you been diagnosed with Chronic Fatigue Syndrome, Irritable Bowel Syndrome, Fibromyalgia or Temporomandibular Syndrome (TMD/TMJ)?

  18. Do you ever notice breathing through your mouth?

  19. Is your mouth ever dry when you wake up?

  20. Have you ever been told you have a “tongue tie?”

  21. Do you have any nasal allergies?

PEDIATRIC QUESTIONNAIRE

 Does your child have trouble going to bed or falling asleep?

Awaken during the night and trouble returning to sleep?

Does he/she tend to breathe through their mouth during the day or during sleep?

Dry mouth or bad breath on waking in the morning?

Have you noticed in your child while sleeping:

Snore or have heavy or loud breathing?

Break or pause in breathing?

Gasp, choke, or struggle to breathe?

Restless or agitated sleep? Grind teeth?

Abnormal head postures (hyperextension, etc)?

Excessive sweating?

Wet the bed?

Have you noticed in your child during the day:

Difficult to awake?

Wakes with headaches? 

Groggy or tired, "out-of -it"? 

Hyperactive?

Teachers commented?

Child often: 

a. Does not seem to listen when spoken to directly? 

b. Has difficulty organizing tasks? 

c. Easily distracted by extraneous stimuli?

d. Fidgets with hands or feet or squirms in seat? 

e. Interrupts or intrudes on others?

Is your child frequently sick, have a history of sore throat, ear infections, sinus infections, or allergies?  

Stop growing at a normal rate at any time since birth? Overweight?

Habits: pacifier/thumb sucking/lip biting/other?