- While sleeping, does your child snore more than half the time?
- While sleeping, does your child always snore?
- While sleeping, does your child snore loudly?
- While sleeping, does your child have "heavy'* or loud breathing?
- While sleeping, does your child have trouble breathing, or struggle to breath?
- Have you ever seen your child stop breathing during sleep?
- Does your child tend to breathe through their mouth during the day?
- Does your child have a dry mouth when waking in the morning?
- Does your child clench or grind their teeth while sleeping?
- Does your child occasionally wet the bed?
- Does your child awake un-refreshed in the morning?
- Does your child experience sleepiness during the day?
- Has a teacher or supervisor commented that your child appears sleepy or sluggish during the day?
- Is it hard to waken your child in the morning?
- Does your child ever wake up with headaches?
- Did your child ever stop growing at a normal rate?
- Is your child overweight?
- This child does not seem to listen when spoken to directly.
- This child often is easily distracted.
- This child often has difficulty organizing tasks and activities.
- This child fidgets or squirms.
- This child is often "on the go" or acts as if "motor driven."
- This child often interrupts or intrudes.
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| ``` PHYSICIAN REFERRAL FORM |
| SLEEP APNEA SELF TEST |
| SLEEP JOURNAL |
|
MARIA SOKOLINA D.D.S. 1066 Clifton Ave. Clifton, NJ 07013-3616 315 W57th Str, Ste 209, NYC, NY 10019 (973) 777-2731 (212) 960-8919 |
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OFFICE HOURS: Mon: 8:00am - 5:00pm | Tue: 8:00am - 7:00pm Wed: 8:00am - 4:00pm | Thu: 8:00am -7:00pm Fri: 8:00am - 3:00pm | Sat: 8:00am - 2:00pm |
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