Schedule an appointment

Schedule an appointment

Schedule an appointment

Home
About Us
Our Services
For Professionals
- Referrals
Health and Wellness Tips
Contact Us

Home
About Us
Our Services
For Professionals
- Referrals
Health and Wellness Tips
Contact Us

Schedule an appointment

Schedule an appointment

Schedule an appointment

Home
About Us
Our Services
For Professionals
- Referrals
Health and Wellness Tips
Contact Us

Elite Dental of Staten Island

2291 Victory Boulevard, Staten Island, NY, 10314

Get Directions (718) 370-1200

Contact Us Today

Business Hours

Monday:

9.00am to 5.00pm

Tuesday:

12.00pm to 8.00pm

Wednesday:

9.00am to 5.00pm

Thursday:

12.00pm to 8.00pm

Friday:

CLOSED

Childrens Airway Questionnaire Banner Image

Give your child the very best

Early treatment is the best way to ensure your child is in good health, and our questionnaire can help put you on the right path

Home Our Services Airway Treatment Take the Children’s Airway Questionnaire

CHILDREN’S AIRWAY QUESTIONNAIRE STATEN ISLAND, NY

Children’s Airway Questionnaire

Could your child’s behavior be linked to airway restriction?

If you answer “yes” to eight or more of the following questions, you should consider referring your child for sleep evaluation.
If your child qualifies for treatment, one of the Elite Dental team members will contact you as soon as possible.

While sleeping, does your child…
Regularly snore?*
- Yes
- No
- Don’t Know
Appear to be a restless sleeper?*
- Yes
- No
- Don’t Know
Snore loudly?*
- Yes
- No
- Don’t Know
Kick out**
- Yes
- No
- Don’t Know
Have “heavy” or loud breathing?*
- Yes
- No
- Don’t Know
Have trouble breathing or struggle to breathe?**
- Yes
- No
- Don’t Know
Have nightmares?*
- Yes
- No
- Don’t Know
Scream in their sleep?*
- Yes
- No
- Don’t Know
Grind their teeth?*
- Yes
- No
- Don’t Know
Have you ever…
Seen your child stop breathing during the night?*
- Yes
- No
- Don’t Know
Does your child…
Tend to breathe through the mouth during the day?*
- Yes
- No
- Don’t Know
Have a dry mouth on waking up in the morning?*
- Yes
- No
- Don’t Know
Occasionally wet the bed?*
- Yes
- No
- Don’t Know
Wake up feeling un-refreshed in the morning?*
- Yes
- No
- Don’t Know
Have a problem with sleepiness during the day?*
- Yes
- No
- Don’t Know
Has a teacher or other supervisor commented that your child appears sleepy during the day?*
- Yes
- No
- Don’t Know
Is it hard to wake your child up in the morning?*
- Yes
- No
- Don’t Know
Does your child wake up with headaches in the morning?*
- Yes
- No
- Don’t Know
Did your child stop growing at a normal rate at any time since birth?*
- Yes
- No
- Don’t Know
Is your child overweight?*
- Yes
- No
- Don’t Know
This child often…
Does not seem to listen when spoken to directly*
- Yes
- No
- Don’t Know
Has difficulty organizing tasks*
- Yes
- No
- Don’t Know
Is easily distracted by extraneous stimuli*
- Yes
- No
- Don’t Know
Fidgets with hands or feet or squirms in seat*
- Yes
- No
- Don’t Know
Is “on the go” or often acts as if “driven by a motor”*
- Yes
- No
- Don’t Know
Interrupts or intrudes on others (e.g. butts into conversations or games)*
- Yes
- No
- Don’t Know
Name*
First Last
Email*
Phone*
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The team at Elite Dental is here to help!
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Ask a question or
book an appointment

Get in touch with the Elite Dental of Staten Island team and see how we can help transform your smile!

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Take the Children’s Airway Questionnaire

2291 Victory Boulevard, Staten Island, NY, 10314

Get in touch

Get in touch with Dr Steve Acker and the Elite Dental of Staten Island team.

2291 Victory Boulevard, Staten Island, NY, 10314

elitedentalofsi@gmail.com

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