Waterloo Heights Dental
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Sleep Disordered Breathing Questionnaire for Children
Earl O. Bergersen, DDS, MSD

Please Select Initial or Follow up option. Select Initial at first appointment, and select follow up after 3 months of treatment. Please identify the following symptoms your child exhibits with the scale indicating severity of symptoms.  



0 – Not Present, 1 – 2 Mild, 3 Moderate, 4 - 5 Pronounced

Does your child:

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


Display hyperactivity


Mouth breathe during day


Mouth breathe while sleeping


Have allergic symptoms


Have frequent headaches in morning


Excessively sweat while asleep


Talk in sleep


Have poor ability in school


Fall asleep watching TV


Wake up at night


Have attention deficit


Have restless sleep


Grind their teeth


Have frequent throat infections


Feel sleepy and/or irritable during the day


Have a hard time listening and often interrupts


Fidget with hands or does not sit quietly


Ever wet the bed


Have bluish color at night or during the day


Have speech problems *

*If yes, provide parent speech questionnaire


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

Based on Sahin et al, 2009; and Urschitz et al, 2004; AM Thoracic Soc Stand, 1996; Attanasio et al, 2010

Speech Questionnaire
To be filled out only if "Does your child: Have speech problems" was scored 1-5

0 – Not Present, 1 – 2 Mild, 3 Moderate, 4 - 5 Pronounced



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 sounds instead of P, F, V, S, Z
sound


Hoarseness


Lisp


Any speech therapy?


How Long?

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