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Smile & Airway Self Assessment

Patient Name

Date

Do you like that way your teeth look?

Yes

No

Do you ever have difficulty eating, chewing, or drinking?

Yes

No

Previous orthodontic treatment?

Yes

No

Have you ever been diagnosed with sleep apnea?

Yes

No

Do you have high blood pressure?

Yes

No

Mouth breading during the day?

Never

Sometimes

Always

Mouth breading at night?

Never

Sometimes

Always

Do you snore?

Never

Sometimes

Always

Grind your teeth?

Never

Sometimes

Always

Experience restless sleep?

Never

Sometimes

Always

Wake up throughout the night?

Never

Sometimes

Always

Night sweats?

Never

Sometimes

Always

Morning headaches?

Never

Sometimes

Always

Digestive issues/stomach aches/acid reflux?

Never

Sometimes

Always

Daytime drowsiness?

Never

Sometimes

Always

Additional information, comments or concerns?

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