Adult Airway Form * First Name Last Name Phone (###) ### #### Email Check all that apply: If any of these apply to you, we can help you! Do you snore at night? Do you wake up feeling tired or not rested? Do you notice your mouth open at rest? Has anyone ever told you that you may be tongue-tied? Have you had troubles with speech or have been in a speech therapy program? Have you experienced any issues with digestion? (Stomach aches, burping, gas, acid reflux, etc) Do you notice that you have a hyper-active gag reflex? Do you have difficulty swallowing pills? Does it ever feel difficult to breathe and eat or chew food at the same time? Have you experienced any breathing issues or difficulties? (chronic congestion, asthma, seasonal allergies, etc.) Have been told your tonsils are enlarged? Have you had your tonsils removed? Do you notice that you tend to breathe through your mouth more often than your nose? Do you wake up nightly to use the restroom? Do you or have you been told that you clench or grind your teeth at night? Thank you!
