Patient notice: COVID cases are on the rise! Patients must wear a face mask at all times, keep distance, and no siblings or more than one parent allowed. Patients will be asked to indicate if they have traveled out of state recently.
(571) 244-7329
Contact Us Now
Virtual Consultation
Menu
Specialists
Areas of Care
Craniofacial Orthopedics
TMJ Diagnosis & Treatment
Orofacial Myology
Orthodontic Solutions
Patient Resources
Patient Forms
Virtual Consultations
Pediatric Sleep Questionnaire
Quality of Life Questionnaire
Financing Information
Media
Blog
Podcasts
Make a Payment
Contact
Request Appointment
Virtual Consultation
Quality of Life Questionnaire
"
*
" indicates required fields
Does your child have difficulty with breathing through the nose? (congestion, colds, ear aches, swollen tonsils, infections)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with keeping lips together at rest? (open mouth, lips apart at rest, chapped lips)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with chewing and swallowing? (uses face muscles, sloppy, noisy, quickly, drooling, tongue tie)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with sitting and standing with good posture? (slouching, forward head, aches or pains)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with eating and nutrition? (picky, difficulty chewing, not nutritious, digestive issues)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with daytime breathing? (Asthma, allergies to food, pollen, animals, toxins, parasites)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with getting a good night's sleep? (restless, snoring, messy bed, awakening, accidents)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with breathing while sleeping? (snoring, heavy breathing, open mouth)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with teeth grinding? (bruxism, clenching, nighttime/daytime)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with body aches or pain? (jaw aches, headaches, migraines, neck or back pain)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with behavioral issues at home or in school? (attention, learning, hyper, sleepy, spectrum)
1
2
3
4
5
6
7
8
9
10
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Full Name
*
Email
*
Name
This field is for validation purposes and should be left unchanged.
Related Pages
Patient Forms
Virtual Consultations
Pediatric Sleep Questionnaire
Quality of Life Questionnaire
Financing Information
Airway & Sleep Group
11800 Sunrise Valley Dr.
Suite 200
Reston, VA 20191
Get Directions
(571) 244-7329
Office Hours
Monday
7:30am – 3pm
Tuesday
7:30am – 3pm
Wednesday
7:30am – 3pm
Thursday
7:30am – 3pm
Menu
