Children (School Functioning)

Children (School Functioning)
TMJ Sleep Relief

This form is for screening purposes only. Positive answers suggest a need for further

evaluation.

• Daytime & Behavior: 2 or more Yes responses suggest potential sleep-related impa on school performance.

Does your child's teacher report difficulty paying attention in class? *YesNo

Has your child been described as overactive, impulsive, or disruptive at school? *YesNo

Does your child have frequent mood swings or irritability? *YesNo

Have school performance or concentration worsened recently? *YesNo

Full Name *

Email Address *

Phone *

Country *