INFANT SLEEP ASSESSMENT | Sleep + Health

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Please select each box that pertains to your child's symptoms.

Infant Questions: (Past or Present) * Required

Painful nursing or shallow latch.

Difficulty latching or staying latched.

Nursing blister.

Clicking or smacking sounds when eating.

Frequent hiccups.

Lots of 'in utero' hiccups.

Prolonged nursing or on the bottle.

Short sleeps or waking often.

Poor or slow weight gain.

Messy eater/milk leakage.

Excessive gassiness or colic.

Reflux/spitting up often.

Nose sounds congested often.

Sleeping with mouth open.

Snoring or noisy breathing when sleeping.

Parent Name

Child Age

Email

Phone

If you checked more than three boxes your infant could be a candidate for Sleep + Health. Would you like to schedule a consult? Just check this box if you consent to letting one of our patient coordinators contact you to schedule. We can't wait to speak with you!

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HOME
EDUCATION
EMFACE & EXION
- EMFACE
- EXION
OUR TEAM
ASSESSMENTS
CONTACT US
PAX DENTAL
More

Use tab to navigate through the menu items.

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