ADULT SLEEP ASSESSMENT | Sleep + Health

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Please select each box that pertains to your symptoms.

Adult Sleep Assessment: (Past or Present) * Required

Difficulty nursing as an infant.

Excessive gassiness or colic as an infant.

Poor or slow weight gain as an infant.

Thumb, finger, or pacifier habit as a child.

Speech delay.

Trouble with certain sounds.

Slow eater/trouble finishing a meal.

Picky eater with textures. (ex: meat, mashed potatoes)

Frequent choking or gagging on foods or liquids.

Crowded/crooked teeth.

Teeth grinding.

Sleeps with mouth open.

Snoring (quiet or loud)/noisy breathing.

Restless sleep.

Wakes easily or often throughout the night.

Upper back/neck/shoulder tension.

TMJ pain/clicking/popping.

Frequent headaches.

Enlarged tonsils and/or adenoids.

Frequent ear infections.

Frequent sinus issues/upper respiratory infections.

Difficulty concentrating/hyperactive.

Diagnosed with sleep apnea.

Full Name

Height (feet'inches)

Age

Weight

Email

Phone

If you checked more than three boxes you could be a candidate for Sleep + Health. Would you like to schedule a consult? Just check this box if you consent to letting one of our patient coordinators contact you to schedule. We can't wait to speak with you!

Thanks for submitting!

HOME
EDUCATION
OUR TEAM
ASSESSMENTS
PAX DENTAL
BLOG
CONTACT US
More

Use tab to navigate through the menu items.

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