Sleep Disordered Breathing Questionnaire for Children

Child's Name *

Date of birth *

Filled out by *

Relationship to child *

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

Sleep

Dental

**Please identify the following symptoms your child exhibits using this scale to indicate the severity of symptoms:

0 = Not Present

1 – 2 = Mild

3 = Moderate

4 - 5 = Pronounced

Does your Child:

Snore at all?

0

1

2

3

4

5

Hyperactive

0

1

2

3

4

5

Mouth breathes while sleeping

0

1

2

3

4

5

Frequent headaches in morning

0

1

2

3

4

5

Allergic symptoms

0

1

2

3

4

5

Excessive sweating while asleep

0

1

2

3

4

5

Talks in sleep

0

1

2

3

4

5

Poor ability in school

0

1

2

3

4

5

Wakes up at night

0

1

2

3

4

5

Restless sleep

0

1

2

3

4

5

Grinds teeth

0

1

2

3

4

5

Frequent throat infections

0

1

2

3

4

5

Feels sleepy and/or irritable during the day

0

1

2

3

4

5

Have a hard time listening and often interrupts

0

1

2

3

4

5

Fidgets with hands or does not sit quietly

0

1

2

3

4

5

Ever wets the bed

0

1

2

3

4

5

Bluish color at night or during the day

0

1

2

3

4

5

Speech Problems

0

1

2

3

4

5

Upload a Selfie

(Optional)

Please take photos of your child's mouth, teeth and face as shown below.

(all pictures and information provided are strictly confidential, in accordance with HIPPA guidelines).

Smiling Selfie

Profile

Is there anything else you would like to let us know?

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