Pediatric questionnaire for children

Pediatric questionnaire for children

The questionnaire should be completed before visiting Unic Orto Clinic.

Answering the following questions will allow the staff to significantly reduce the patient’s registration time before the first consultation. The answers will be used during the visit for the dental examination and further diagnostics. Also, your doctor may ask additional questions. All information provided is covered by medical confidentiality and is for the sake of your safety. If you are unsure, please ask the registration desk before your scheduled appointment or the doctor during your consultation for clarification.

    Personal data

    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?

    Blood diseases?


    Clotting diseases?

    Thyroid diseases?

    Metabolic diseases (e.g. diabetes, gout)?

    Neurological diseases?

    Genetic diseases?



    Kidney disease?

    Liver disease?

    Allergies? If so, what kind?

    ENT diseases (e.g. tonsillitis, allergic reactions)? If so, what kind?

    Other? If so, what kind?

    Is the patient on permanent medications? If so, what kind?

    Orthodonitic questionnaire

    1. Type of delivery (it affects muscle tension, development of malocclusion)

    2. Was the baby breastfed? If so, for how long?

    3. What consistency of food was introduced to the child and at what age?

    4. Has the child participated in speech therapy? If so, for what reason?

    5. Was there a shortened frenulum of the tongue or lip?

    6. Was there a finding of decreased muscle tone?

    7. Have there been/are any habits: If so, what kind?

    8. How does the child breathe during the day? If by mouth, in what situations (select all true)

    9. How does the child breathe while sleeping?

    10. Is the child nose?

    11. Are there any posture defects? If so, what kind?

    12. Do any of the following occur?

    Pediatric sleep questionnaire

    It gives us information about possible hypoxia during sleep.

    Does your child:

    1. Snore more than half the night?

    2. Snore often?

    3. Snore loudly?

    4. Breathe noisy or heavy?

    5. Is having trouble breathing or gasping for breath?

    6. Have you ever seen your child stop breathing while sleeping?

    7. Breathe through mouth during the day?

    8. Wakes up with a dry feeling in his throat?

    9. Occasionally wets the bed at night?

    10. Wakes up tired?

    11. Is sleepy during the day?

    12. Has the teacher or other caregiver noticed that the child is lethargic during the day?

    13. Has trouble getting up in the morning?

    14. Wakes up with a headache?

    15. Did not grow properly at any time?

    16. Is overweight?

    17. Seems not to listen when you talk to him?

    18. Has trouble organizing or completing tasks/responsibilities?

    19. Is easily distracted by external stimuli?

    20. Is sitting restlessly, is wriggling?

    21. Is constantly moving as if it were powered by a motor?

    22. Is disturbing others in conversation or play?

    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.

    *In order to send the questionnaire, please accept our privacy policy and patient declaration

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