Strathcona Orthodontics

7528 Gateway Blvd Edmonton, Alberta T6E 6E8
t. 780-435-3641 f. 780-436-4354 tf. 1-877-229-4733 e. braces@str8teeth.com

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- Terry Carlyle DDS, MSc.
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Child Airway Assessment

*Patient Name Height feet/inches metric (m) Weight pounds (lbs) kilograms (kg)

Do you have difficulty breathing through your nose?

No Yes If yes: mildmoderate severe

Do you breathe through your mouth when you sleep?

NoYes If yes: occasionallyalways

Do you breathe through your mouth during the day?

NoYes If yes: occasionallyalways

Do you snore?

NoYes If yes: mildmoderatesevereloudly

Are you tired during the day?

NoYes If yes: occasionallyalways

Has anyone observed you stop breathing during sleep?

NoYes

Do you have sleep apnea?

NoYes If yes: mildmoderatesevere

Do you have difficulties sleeping at night?

NoYes If yes: mildmoderatesevere

Do you clench and/or grind your teeth at night?

NoYes If yes: mildmoderatesevere

Do you wake up with headaches in the morning?

NoYes If yes: mildmoderatesevere

Do you wake up at night unable to catch your breath?

NoYes If yes: occasionallymoderatelyfrequently

Do your legs and/or arms jerk at night?

NoYes

Do you sleep on your:

Back Sides Stomach

Adolescents (14 and older) only

Do you have or have you been treated for high blood pressure?

NoYes If yes: mildmoderatesevere

Do you smoke?

NoYes

If yes,packs per daycigarettes per day

Your e-mail addressTo receive a confirmation, please include your email address.

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