Sleep Disordered Breathing Questionnaire for Children

Doctor

Child's Name

Age

Date

Filled Out By

Relationship To Patient

Sleep Assessment

Please identify the following symptoms your child exhibits with the scale indicating severity of symptoms. (0, 1-2 Mild, 3 Moderate, 4-5 Pronounced)

Snore at all

Snore only infrequently (1 night/week)

Snore fairly often (2-4 nights/week)

Snore habitually (5-7 nights/week)

Have labored, difficult, loud breathing at night

Have interrupted snoring where breathing stops for 4 or more seconds

Have stoppage of breathing more than 2 times in an hour

Hyperactive

Mouth breathes during day

Mouth breathes while sleeping

Frequent headaches in morning

Allergic symptoms

Excessive sweating while asleep

Talks in sleep

Poor ability in school

Falls asleep watching TV

Wakes up at night

Attention deficit

Restless sleep

Grinds teeth

Frequent throat infections

Feels sleepy and/or irritable during the day

Have a hard time listening and often interrupts

Fidgets with hands or does not sit quietly

Ever wets the bed

Bluish color at night or during the day

Speech Problems

Was your reason for coming to this doctor for sleep or dental issues

Speech Questionnaire

To be filled out only if Speech Problems was indicated above. Please check all that apply to your child:

Is it difficult to understand your child's speech

Difficult to understand over the phone

Nasal speech

Speech sounds abnormal

Others have difficulty understanding speech

Gets frustrated when people can't understand speech

Sometimes omits consonants

Uses M, N, NG instead of P, F, V, S, Z sounds

Hoarseness

Lisp

Any speech therapy

How Long was speech therapy?

Patient Name Validation

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