Tao Dental Care
www.dentaltao.com, 10011 N. Foothill Blvd #109, Cupertino, CA 95014, yuan.tao.dmd@gmail.com, (408) 737-2988
General Pediatric Sleep Questionnaire
Patient Name
Last Name
First Name
Middle Name
Phone Number
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Area Code
Phone Number
Date
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Month
-
Day
Year
Date
Does your Child…? (check all that apply)
Tend to breathe through the mouth during the day
Have a dry mouth upon waking up in the morning
Occasionally wet the bed
Grind his/her teeth while sleeping
Have any bite problems or crowded teeth
Wake up unrefreshed in the morning
Have a problem with daytime sleepiness
Have a teacher or anyone who has commented about sleepiness during the day
Have difficulty waking up in the morning
Wake up with headaches
Abnormal head postures (Hyperextension, etc.) during sleep
Excessive sweating during sleep
Have any history of growth problems
Have an overweight issue:
Weight is
Height is
Complain of restless or achy legs
Have arms and /or legs that twitch during sleep
Have nightmares (More than one per week)
While Sleeping, Does your Child: (check all that apply)
Snore more than half the time
Always Snore
Snore loudly
Have heavy or loud breathing
Have trouble breathing or struggles to breathe
Break or pause in breathes?
Gasp, choke or struggle to breathe?
Ever stop breathing at night?
Submit
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