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19465 Deerfield Ave #406•Leesburg, VA•(703) 723-7810

Patient Info

Adult Airway &
Sleep Questionnaire

Could your headaches, fatigue, jaw tension or changing teeth be connected to how you breathe and sleep? Answer seven quick questions, and our team will follow up to talk through what your answers may mean.

This is a screening tool, not a diagnosis. If your answers suggest an evaluation could help, a member of the Lansdowne Dental Care team will contact you as soon as possible. Have a child? Take our Pediatric Sleep Questionnaire.

Please answer the following…

Do you suffer from nasal congestion, allergies or have difficulty breathing through your nose?
Do you wake up feeling fatigued or suffer from daytime sleepiness?
Do you have morning tension or migraine headaches?
Do you clench or grind your teeth during the day or at night?
Do you have more than one bite, or do you find yourself posturing your lower jaw forward?
Have your teeth changed in the last 5 years (for example, more space, more crowding, or increased wear and fractures)?
Is there anything you don’t like about your smile?
This questionnaire is for screening purposes only. A member of our team will follow up with you.

Call Our Office Today

(703) 723-7810

We are located in Leesburg, VA but proudly serve Lansdowne, Reston, Broadlands, Ashburn, Sterling, and all neighboring communities.