Dr. Montano would like you to complete this form as accurately and as honestly as possible. In our practice, we are very interested in our patients’ overall health. Orthodontic treatment can be an important part of managing the health problems caused by sleep and breathing disorders.

Please write “Y” for Yes and “N” for No:

• While sleeping, does your child snore more than half the time? YesNo

• While sleeping, does your child always snore? YesNo

• While sleeping, does your child snore loudly? YesNo

• While sleeping, does your child have “heavy” or loud breathing? YesNo

• While sleeping, does your child have trouble breathing, or struggle to breath? YesNo

• Have you ever seen your child stop breathing during the night? YesNo

• Does your child occasionally wet the bed, sleepwalk, or have night terrors (circle any)? YesNo

• Does your child tend to breathe through the mouth during the day? YesNo

• Does your child have a dry mouth on waking up in the morning? YesNo

• Does your child wake up unrefreshed in the morning? YesNo

• Does your child wake up with headaches in the morning? YesNo

• Is it hard to wake your child up in the morning? YesNo

• Does your child have a problem with sleepiness during the day? YesNo

• Has a teacher or supervisor commented, “your child appears sleepy during the day”? YesNo

• Did your child stop growing at a normal rate at any time since birth? YesNo

• Is your child overweight? YesNo

• This child often does not seem to listen when spoken to directly. YesNo

• This child often has difficulty organizing task and activities. YesNo

• This child often is easily distracted by extraneous stimuli. YesNo

• This child often fidgets with hands or feet or squirms in seat. YesNo

• This child often is ‘on the go’ or often acts as if ‘driven by a motor’. YesNo

• This child often interrupts or intrudes on others (butts into conversations or games). YesNo

• Total “Y” Answers =