KID SLEEP ASSESSMENT | Sleep + Health

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Please select each box that pertains to your child's symptoms.

Child Sleep Assessment: (Past or Present)

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.

Parent Name

Child Age

Email

Phone

If you checked more than three boxes your child 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!

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HOME
EDUCATION
OUR TEAM
ASSESSMENTS
PAX DENTAL
CONTACT US
More

Use tab to navigate through the menu items.

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