Airway Questionaire
Please print, fill out, and either fax, mail or bring this form with you to our office.

Many children with orthodontic problems have partially obstructed nasal air passages and breath through their mouths more than is normal. An accurate record of your child's breating habits, both while asleep and awake, will be very happy.

Does your child breath through his/her mouth while he/she is awake?
All of the time
Most of the time
Only during colds
Hardly ever

Does your child breath through his/her mouth while he/she is asleep?
All of the time
Most of the time
Only during colds
Hardly ever

Does your child snore when asleep?
Yes, loudly
Yes, softly
No, but his/her breathing is audible when he/she sleeps
Quiet sleeper

Does your child sigh a lot in the daytime? Yes No

Is your child a restless sleeper?
Awakens often, gets out of bed
Thrashed around
Changes positions frequently
Wets the bed more than occasionally
Can only sleep in a certain position
Has frequent nightmares
Not restless

Can your child swallow normally?
Chews with mouth open
Gags on food more than occasionally
Hardly chews his/her food
Protrudes tongue when swallowing
Swallows normally

Do you notice periods of time during your child's sleep when he/she seems to stop breathing for over ten seconds at a time?
Frequently
Occasionally
No

I hereby state that I have truthfully to the best of my ability answered all the above questions.

SIGNATURE/PARENT-GUARDIAN DATE_______________

Revised 10-2-92