110 Professional Park Dr. Victoria, TX 77904

ADULT Airway Questionnaire

    Are you frequently sick ie, cold

    Fatigue

    Morning Headaches

    Myalgia-Muscle aches, pains, soreness

    Difficulty Concentrating

    Need caffeine throughout the day

    Frequent neck soreness

    TMD Pain
    Forgetfulness

    Claustrophobia

    Heightened gag reflex

    Encumbered airway, subjectively

    Small nasal openings

    Enlarged Turbinates (tiny bone plates in nose)
    Frequent sore throat

    Deviated Septum

    Post nasal drip

    Frequent sinus/nasal congestion

    Sinusitis

    Sleep Disturbances:

    Frequent nightly awakenings

    Difficulty initiating sleep

    Insomnia – difficulty maintaining sleep

    Night-time bathroom trips

    Bruxism, teeth grinding, clenching

    Restless Leg Syndrome

    Unrefreshed sleep

    GERDS/ acid reflux

    Snoring

    Light Sleeper

    Dry Mouth at night or awakening

    Chapped Lips

    Sleep Position:

    Regular use of sleep aids

    Sinusitis (frequent)

    Chronic cough or throat cleaning

    Sinus migraines

    Nasal Polyps

    Halitosis (bad breath)

    Frequent nosebleeds

    BMI – High/ Low

    Neck Size (male>17/Female>16

    Altered smell

    Asthma

    Lip/chin strain to close to mouth

    Rhinitis (frequent)

    Nasal Obstruction

    Breathing pattern: Open-Mouth-Overbreathing

    Functional Somatic Syndrome:

    Depression

    Chronic Fatigue Syndrome

    Irritable Bowel Syndrome

    Fibromyalgia

    Polysomatic Disorder

    Mood Swings/Irritability

    Anxiety/Panic Attacks

    Orthodontic History:




    Teeth Extracted?

    History of Headgear

    History of palatal expansion

    History of functional appliances

    Autonomic Nervous System:

    Hypotension - Low blood pressure

    Osthostasis-light headed when standing up

    Cold hands and feet

    Unexplained shaking at night

    History of latent bed wetting

    Night sweats

    Neurologic:

    Balance/Tripping

    Constipation

    Tingling in hands

    Pill rolling

    Hand/Arm hanging while walking

    Nighttime drooling

    American Academy of Clear Aligners logo
    AADSM Qualified Dentist logo
    American Academy of Physiological Medicine & Dentistry logo
    American Dental Association logo
    Academy of General Dentistry logo
    Invisalign® Provider logo
    Comprehensive Family Dental Logo

    Our office is conveniently located off East Mockingbird Lane, between John Stockbauer Rd., and Sam Houston Dr.

    ADDRESS

    110 Professional Park Dr.
    Victoria, TX 77904

    HOURS

    Mon - Thu
    8:00AM - 5:00PM