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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



Any speech therapy?

How Long?

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