Name and phone number of the dentist the patient goes to:
How did you find out about us?
How much time do you need to get to our clinic?
What is the most important reason for bringing your child to an orthodontist?
What expectations do you have for your child's dental treatment?
Patient's medical history Please answer the following questions.
Does the patient suffer from: Heart diseases?
YES NO DON'T KNOW
Blood diseases?
YES NO DON'T KNOW
Hypertension?
YES NO DON'T KNOW
Clotting diseases?
YES NO DON'T KNOW
Thyroid diseases?
YES NO DON'T KNOW
Metabolic diseases (e.g. diabetes, gout)?
YES NO DON'T KNOW
Neurological diseases?
YES NO DON'T KNOW
Genetic diseases?
YES NO DON'T KNOW
Epilepsy?
YES NO DON'T KNOW
Cancer?
YES NO DON'T KNOW
Kidney disease?
YES NO DON'T KNOW
Liver disease?
YES NO DON'T KNOW
Allergies?
YES NO DON'T KNOW
ENT diseases (e.g. tonsillitis, allergic reactions)?
YES NO DON'T KNOW
Other?
YES NO DON'T KNOW
Is the patient on permanent medications?
YES NO
Orthodonitic questionnaire
1. Type of delivery (it affects muscle tension, development of malocclusion)
Natural Caesarean section
2. Was the baby breastfed?
YES NO
3. What consistency of food was introduced to the child and at what age?
4. Has the child participated in speech therapy?
YES NO
5. Was there a shortened frenulum of the tongue or lip?
YES NO
6. Was there a finding of decreased muscle tone?
YES NO
7. Have there been/are any habits:
Baby pacifier Thumb sucking Other
8. How does the child breathe during the day?
Nose Mouth While playing During concentration While car drive While watching TV While walking While sitting
9. How does the child breathe while sleeping?
Nose Mouth
10. Is the child nose?
Usually clear Often clogged Always clogged
11. Are there any posture defects?
YES NO
12. Do any of the following occur?
ADHD Dyslexia Autism spectrum disorders Selective mutism None of the above
Pediatric sleep questionnaire It gives us information about possible hypoxia during sleep.
Does your child: 1. Snore more than half the night?
YES NO DON'T KNOW
2. Snore often?
YES NO DON'T KNOW
3. Snore loudly?
YES NO DON'T KNOW
4. Breathe noisy or heavy?
YES NO DON'T KNOW
5. Is having trouble breathing or gasping for breath?
YES NO DON'T KNOW
6. Have you ever seen your child stop breathing while sleeping?
YES NO DON'T KNOW
7. Breathe through mouth during the day?
YES NO DON'T KNOW
8. Wakes up with a dry feeling in his throat?
YES NO DON'T KNOW
9. Occasionally wets the bed at night?
YES NO DON'T KNOW
10. Wakes up tired?
YES NO DON'T KNOW
11. Is sleepy during the day?
YES NO DON'T KNOW
12. Has the teacher or other caregiver noticed that the child is lethargic during the day?
YES NO DON'T KNOW
13. Has trouble getting up in the morning?
YES NO DON'T KNOW
14. Wakes up with a headache?
YES NO DON'T KNOW
15. Did not grow properly at any time?
YES NO DON'T KNOW
16. Is overweight?
YES NO DON'T KNOW
17. Seems not to listen when you talk to him?
YES NO DON'T KNOW
18. Has trouble organizing or completing tasks/responsibilities?
YES NO DON'T KNOW
19. Is easily distracted by external stimuli?
YES NO DON'T KNOW
20. Is sitting restlessly, is wriggling?
YES NO DON'T KNOW
21. Is constantly moving as if it were powered by a motor?
YES NO DON'T KNOW
22. Is disturbing others in conversation or play?
YES NO DON'T KNOW
Enter the sum of the answers "YES"
If the answer of "YES" is more than 8 it may mean significant sleep and breathing disorders. You should do a sleep study. 