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Home
Our Services
Adult Orthodontics / Clearcorrect
Smile Makeover
Treatment for headaches
Nervous patients
Children’s Orthodontics / Myobrace
Teeth whitening
Dental Treatment
Mouthguards
Families
Implants
Crowns
Root canal treatment
Removal of silver fillings
Oral Hygiene
Clearcorrect
Smile Gallery
Adult Orthodontics / Clearcorrect
Children’s Orthodontics / Myobrace
Composite Bonding
Dental Implants
Smile Makeovers
Tooth Whitening
About Us
Blog
Contact Us
Online Booking
Myosleep kids questionnaire
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Myosleep kids questionnaire
Dr. Christa Engelbrecht Dental
Myosleep Kids' Questionnaire
Please answer the following questions based on your child's average sleep habits/quality during the past month.
Patient Name
First
Last
Date of Birth
MM slash DD slash YYYY
Does your child have a problem going to bed or falling asleep?
(Required)
Yes
No
Unsure
Does your child tend to have an irregular bed time?
(Required)
Yes
No
Unsure
Does your child tend to have an irregular wake time?
(Required)
Yes
No
Unsure
Does your child's bedtime/wake time differ greatly between weekdays and weekends?
(Required)
Yes
No
Unsure
Does your child wake up often during the night after falling asleep?
(Required)
Yes
No
Unsure
Does your child have their mouth open while sleeping?
(Required)
Yes
No
Unsure
Does your child have heavy or loud breathing habits while asleep?
(Required)
Yes
No
Unsure
Does your child snore for more than half of the night's sleep duration?
(Required)
Yes
No
Unsure
Does your child always snore while sleeping?
(Required)
Yes
No
Unsure
Does your child always snore loudly?
(Required)
Yes
No
Unsure
Does your child have difficulty breathing at night while sleeping?
(Required)
Yes
No
Unsure
Does your child ever stop breathing while sleeping?
(Required)
Yes
No
Unsure
Does your child have regular nightmares, sleep walk or have other unusual sleep behaviours?
(Required)
Yes
No
Unsure
Does your child occasionally wet the bed?
(Required)
Yes
No
Unsure
Does your child have a dry mouth when they wake up in the morning?
(Required)
Yes
No
Unsure
Does your child find it difficult to wake in the morning?
(Required)
Yes
No
Unsure
Does your child wake up feeling unfreshed in the morning?
(Required)
Yes
No
Unsure
Does your child seem overly tired or take excessive naps during the day for their age?
(Required)
Yes
No
Unsure
Does your child wake up with headaches in the morning?
(Required)
Yes
No
Unsure
Do you think your child is failing to get enough sleep for his/her age?
(Required)
Yes
No
Unsure
Has a teacher or supervisor commented that your child appears unusually sleepy during the day?
(Required)
Yes
No
Unsure
Does your child tend to breathe through the mouth while awake?
(Required)
Yes
No
Unsure
Is your child's overall growth slower than the average child for their age?
(Required)
Yes
No
Unsure
Is your child overweight?
(Required)
Yes
No
Unsure
Does your child have difficulty organising tasks and activities for their age?
(Required)
Yes
No
Unsure
Does your child appear to not listen when spoken to directly?
(Required)
Yes
No
Unsure
Does your child get easily distracted?
(Required)
Yes
No
Unsure
Does your child appear to fidget or struggle to sit still?
(Required)
Yes
No
Unsure
Is your child hyperactive?
(Required)
Yes
No
Unsure
Please provide any additional feedback that may be relevant to your child's sleep habits?
Form completed by:
First
Last
Date
MM slash DD slash YYYY