Tao Dental Care
www.dentaltao.com, 10011 N. Foothill Blvd #109, Cupertino, CA 95014, yuan.tao.dmd@gmail.com, (408) 737-2988
PEDIATRIC QUESTIONNAIRE
1. Does your child have trouble going to bed or falling asleep?
Yes
No
2. Awaken during the night and have trouble returning to sleep?
Yes
No
3. Does he/she tend to breathe through their mouth during the day or during sleep?
Yes
No
4. Have dry mouth or bad breath upon waking in the morning?
Yes
No
5. Have you noticed any of the following while your child is sleeping (Check all that apply):
Snoring, heavy or loud breathing
Break or pause in breathing
Gasp, choke, or struggle to breathe
Restless or agitated sleep
Grinding teeth
Abnormal head posture (hyper-extension, etc.)
Excessive sweating
6. Have you noticed any of the following during the day (Check all that apply):
Difficulty waking
Wakes with headaches
Groggy, tired or "out of it"
Hyperactive
7. Child Often (check all that apply):
Easily distracted by extraneous stimuli
Has difficulty organizing tasks
Interrupts or intrudes on others
Fidgets with hands or feet or squirms in seat
8. Is your child frequently sick, have history of sore throat, ear infections, or sinus infections?
Yes
No
9. Stop growing at a normal rate at any time since birth? Overweight?
Yes
No
10. Habits such as: pacifier/ thumb sucking/ lip biting/ other?
Yes
No
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