Adult Airway form Step 1 of 6 16% InstagramThis field is for validation purposes and should be left unchanged.SnoringDo you have any snoring habits listed below?Do you snore? Quietly? Loudly? Yes No Don’t Know Snore more than half the time? Yes No Don’t Know Breathing During SleepingHave you noticed any of the following with your breathing during sleep?Have trouble breathing, or struggle to breathe? Yes No Don’t Know Have “heavy” or loud breathing? Yes No Don’t Know Stop breathing during the night? Yes No Don’t Know Sleep DisordersHave you noticed any of the following when you are sleeping?Have trouble going to bed or falling asleep? Yes No Don’t Know Awake during the night and have trouble returning to sleep? Yes No Don’t Know Do you grind your teeth? Yes No Don’t Know Have you ever had a sleep study or been diagnosed with a sleep disorder? Yes No Don’t Know Waking Up/Starting Your DayHave you noticed any of the following when starting your day?Do you wake up with headaches? Yes No Don’t Know Do you wake up with a dry mouth? Yes No Don’t Know Do you tend to breathe through the mouth during the day? Yes No Don’t Know Throughout Your Day/Health HistoryHave you noticed any of the following during the day or past health issues?Do you have difficulty organizing tasks? Yes No Don’t Know Are you easily distracted? Yes No Don’t Know As a child, were you frequently sick, history of sore throats, ear infections, sinus infections or allergies? Yes No Don’t Know Result: Airway Assessment RecommendedOn analysis, your child could definitely benefit from our complimentary orthodontic airway assessment. We suggest scheduling an appointment for that here:Result: No Concern at this TimeThere doesn’t seem to be too much concern regarding your child’s airway, which is amazing news! Be vigilant about all the previous symptoms and take the questionnaire again if you are concerned. If you would still like to schedule an assessment, fill out the form below to setup an appointment.Name(Required) First Last Email(Required) Phone(Required)SMS Consent(Required) I consent to receive SMS text messages from Hamilton & Manuele Orthodontics.I consent to receive SMS text messages from Hamilton & Manuele Orthodontics. Msg & data rates may apply. Reply STOP to opt out.This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
