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(Can be filled out in-office OR If you would like a form emailed to you prior to your visit, please call our office)

Sleep Disordered Breathing Questionnaire for Children

Please indicate to what degree your child exhibits any of the following symptoms using the scale of severity below. The initial score column should be evaluated and dates at first appointment and the follow-up score column should be evaluated and dated after 3 months of treatment by the same person who filled out the initial assessment.

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Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounce: 4

Severe: 5

INITIAL
SCORE
FOLLOW-UP
SCORE

1.

Snoring of any kind

2.

Snores only infrequently (1 night/week)

3.

Snores fairly often (2-4 nights/week)

4.

Snores habitually (5-7 nights/week)

5.

Has labored, difficult, loud breathing at night

6.

Has interrupted snoring where breathing stops for 4 or more seconds

7.

Had stoppage of breathing more than 2 times in an hour

8.

Hyperactive

9.

Mouth breathes during day

10.

Mouth breathes while sleeping

11.

Frequent headaches in morning

12.

Allergic symptoms

13.

Excessive sweating while asleep

14.

Talks or walks in sleep

15.

Poor ability in school*

16.

Falls asleep watching TV or at school

INITIAL
SCORE
FOLLOW-UP
SCORE

17.

Wakes up at night

18.

Attention deficit

19.

Restless Sleep

20.

Grinds Teeth

21.

Frequent throat or other infections

22.

Frequent ear infections

23.

Feels sleepy and/or irritable during the day

24.

Has a difficult time listening and often interupts

25.

Fidgets with hands or does not sit quietly*

26.

Ever wets the bed

27.

Exhibits bluish color at night or during the day or under eyes

28.

Nightmares and/or night terrors

29.

Exhibits any of the following*:

30.

Speech problems**

31.

Nasal breathing difficult

32.

Resists rountines and directions

*Please indicate with a X if condition is present

** If scored greater than 0, please continue to Speech Questionnaire on page 2 (reverse side)Please indicate with a X if condition is present

Not Present: 0

Very Mild: 1

Mild: 2

Moderate: 3

Pronounce: 4

Severe: 5

Speech Assessment

INITIAL
SCORE
FOLLOW-UP
SCORE

33.

Do you or do others have difficulty 41. understand your child’s speech?

34.

Difficult to understand over the phone

35.

Uses grunts or screams more than words

36.

Lisp

37.

Hoarseness

38.

Nasal speech

39.

Becomes frustrated when attempting to speak

40.

Often uses words with only 1 or 2 syllables

INITIAL
SCORE
FOLLOW-UP
SCORE

41.

Seems winded when increasing volume

42.

Any difficulty in swallowing

43.

Stutters ⭢ Any family history of a stutter?

44.

Tourette’s Syndrome

45.

Family history of a speech or language disorde

46.

Any speech therapy?

Specific Articulation Questions

INITIAL
SCORE
FOLLOW-UP
SCORE

47.

Child replaces a “t, d, n, s, z, th or l” with a “p, b, m, w, f, or v”

Example: “hap” for “hat”, “kif” for “kiss”, “fum” for “thumb”, or “bav” for “bath”

48.

Child replaces an “r” with a “w” or an “L” with a “w” or a “y”

Example: “wabbit” for “rabbit”, “ “yewo” for yellow” “weg” for “leg”, “pway” for “play”, “wun, for “run”

49.

Child replaces a “s, f, v, z, th, j, or h” with a consonant such as “p, b, t, d, k, g”

Example: “tock” for “sock”, “dump” for “jump”, “pan” for fan”, “bat” for “fat”

50.

Child replaces a “p, b, m, w, th, f, or v” with a “t, d, s, z, n, or l”

Example: “sum” for “thumb”, “muhzer” for “mother”

51.

Child replaces a “t” or a “d” with “k” or “g”

Example: “gog” for “dog”, “cop” for “top”, “boke” for “boat”, “key” for “tea”

INITIAL
SCORE
FOLLOW-UP
SCORE

52.

Child replaces a “ch” or a “j” sound with a “sh, v, f, th, or s”

Example: “ship” for “chip”, “shoo shoo” for “choo choo”

53.

Child changes position of a sound within a word

Example: “pasghetti” for “spaghetti”, “efelant” for “elephant”, “baksit” for “basket”

54.

Child inserts “uh” into words

Example: “stuh-reet” for “street”, “fuh-wog” for “frog”, “buh-lue” for “blue”, “puh-lease” for “please”

55.

Child replaces a “k” or a “g” with “t” or “d”

Example: “doat” for “goat”, “tuhtie” for “cookie”, “tup” for “cup”, “hud” for “hug”

56.

Child replaces a “sh” with an “s”

Example: “sue” for “shoe”, “sip” for “ship”, “mezza” for “measure”

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