Evergreen Pediatric & Airway Dentistry

12910 Totem Lake Blvd NE #103, Kirkland, WA 98034

425-814-3196

Kids Sleep Survey

The questionnaire has been designed to determine how your child is

managing their sleeping and if it is affecting their daily life.

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 *

NEXT

Unlock insights on sleep apnea and our holistic treatment approach

Copyright 2024 Evergreen Pediatric & Airway Dentistry

Terms & Conditions