Do you or your child/loved one experience behavioral problems or trouble concentrating? *

Experience irritability, often losing your/their temper? *

Experience or are being treated for chronic pain and/or fatigue? *

Been diagnosed with or treated for a chronic inflammatory condition such as cardiovascular disease, diabetes, obesity, or memory loss? *

Constantly feel tired and yawn frequently during the day? *

Breathe through your/their mouth, snore loudly, or grind teeth while sleeping? *

Wake up during the night one or more times? *

Have experienced or noticed daytime breathing problems, such as open-mouth breathing, frequent blocked or stuffy nose, noisy breathing and/or breathing with the chest instead of the belly? *

Experience difficulty swallowing liquids, soft foods, solid foods, and/or pills/vitamins? *

Have any or all of the following; tongue- or lip-tied, stuttering, lisp, difficulty forming words or speaking, or delayed speech? *

Have noticed, been made aware of, or is affected by any or all of the following dental issues: over-bite (upper teeth overlap bottom teeth), under-bite (bottom teeth project beyond upper teeth), cross-bite (one or more teeth are tilted toward the cheek or tongue when compared to the tooth above or below it), too much space between teeth, narrow jaw, or a large or protruding tongue? *