Airway Referral Form

Young boy pointing to his smile in the dental office
Male Female
Adenoid Hyperplasia Allergic Shiners/Dark Circles Apnea Ankyloglossia/Tongue Tie Lip Tie Bedwetting Behavioral/Attention Problems Chronic Congestion Daytime Sleepiness Gasping Grinding Large Tonsils Lip Incompetence Night Terrors Open Mouth Posture/Breathing Restless Sleep Sleep Disturbances Snoring
Dental Crowding Increased Lower Facial Height/Vertical Growth Maxillary/Mandibular Deficient Narrow Palate Retroclined Anteriors Sleep Palate Gummy Smile Deep Bite Crossbite
Yes No