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
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, Zsound
Hoarseness
Lisp
Any speech therapy?
How Long?
