First Name

Last Name

Email *

Phone *

This self-assessment will not replace a one-on-one consultation with a qualified healthcare provider. This self-assessment is not intended to diagnose, treat, prevent or cure any healthcare condition.

Please Accept The Terms & Conditions

I Accept

I Do Not Accept

Your Patient Care Coordinator can help you understand what your assessment responses mean, discuss potential treatment options and answer your questions.

Which of these problems is of the highest priority for your child right now? Choose only ONE: *

- ADD/ADHD

- Snoring/ Mouth Breathing

- Improper speech/ thumbsucking

- Bedwetting

- Asthma/ Allergies

- Headaches / Pain

- Behavior/ Difficulty in School

- Crowded teeth/Improper jaw size or relationship

Let's Consider your child’s sleeping habits. Do they experience any of the following during sleep? Check all that apply:

Snoring

Nightmares

Trouble falling or staying asleep

Restless Sleep

None of the above

Does your child experience any of the following? Check all that apply:

Waking Feeling Tired

Morning Headaches

Irritable/Short-tempered behavior

Daytime Tiredness

Difficulty Concentrating

Anxiety/Stress

Feeling Overwhelmed

Memory Problems

None of the above

Do your child currently take medications (over-the-counter or prescribed) for any of the following? Check all that apply:

Allergies/Asthma

Depression/Anxiety

ADHD

Pain

None of the above

Child Age *

• 2-4

• 5-8

• 9-12

• Over 13

Let's talk about your child’s oral health. Select all that apply:

Tongue tied/ had trouble breastfeeding

Have had teeth extracted

Have worn braces to straighten teeth

Probably should have worn braces

Have had their tonsils or adenoids removed

Have significant decay/fillings

None of the above

Has your child ever taken a home sleep study?

Yes

Has your child been diagnosed by a physician with mild-to-moderate obstructive sleep apnea or sleep disordered breathing, ADHD, or anxiety/depression?

Yes

Tell us in your words

How have these problems affected your life, and what would you like to see changed?