NoPo Dental and Medical History Forms

Other than when sick, does your child typically breathe with his/her mouth open or lips apart, either while awake or asleep?

Other than when sick, does your child SNORE or have pauses in breathing or STOP breathing while sleeping, or does your child have noisy breathing or difficulty breathing while awake?

While sleeping, does your child frequently do ANY of the following: toss and turn, kick, sleepwalk or talk in their sleep or grind or clench teeth, sleep on stomach, kneel, or sleep with the head extended backwards/upwards?

In the morning, other than when sick, does your child frequently have ANY of the following: difficulty waking up, nasal congestion, dry mouth, jaw pain, or headaches?

Does your child frequently have ANY of the following: unusual sleepiness or tiredness during the day, difficulty sitting still, concen trating, problems with behaviors, emotions, or poor school performance?

*Airway evaluation questions used with consent of CAST (Children's Airway Screener Taskforce)

IF YES TO ANY OF THE ABOVE SLEEP AND AIRWAY QUESTIONS, PLEASE COMPLETE THE AIRWAY AND SLEEP

How is your child's gut health? Does your child have consistent, well formed, and daily bowel movements?

Does your child have regular constipation or diarrhea?

YesNo

Has your child had exposure to any of the following?

Does your child have regular constipation or diarrhea?

YesNo

Exposure to any other environmental toxins?

YesNo

Do you have the following in your home?

Air FilterWater FilterBothNone

Do you have pets in your home?

YesNo

Has your child been admitted to the hospital in the last 2 years?

YesNo

Does your child have any history of surgery?

YesNo

Does your child have any other health concerns/issues?

YesNo

Pediatrician Office Name

Pediatrician Name

Pediatrician Phone #

When was your child's last visit to the Pediatrician?

Please list any concerns discussed:

If referred by another office is your child a patient of record at that location?

YesNo

Please Read and Acknowledge by check the box

To the best of my knowledge, all of the preceding information is true and correct. If any changes occur with the health of my child, I will inform the office at the next dental appointment without fail.

Signature*

Relationship to Patient*

Name if not the patient

Sleep and Airway Questions