Healthy Start

Sleep Disordered Breathing Questionnaire

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Doctor/Dentist *

Patient's Name *

First

Last

Date of Birth *

Age *

Filled Out By *

Relationship to Patient *

Please indicate to what degree your child exhibits any of the following symptoms using the scale of severity:

Snoring of any kind *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Snores only infrequently (1 night/week) *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Snores fairly often (2-4 nights/week) *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Snores habitually (5-7 nights/week) *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Has labored, difficult, loud breathing at night *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Has interrupted snoring where breathing stops for 4 or more seconds *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Has stoppage of breathing more than 2 times in an hour *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Hyperactive *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Mouth breathes during day *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Mouth breathes while sleeping *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Frequent headaches in morning *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Allergy symptoms *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Please indicate if condition is present *

Asthma
Eczema
Nasal congestion
Other

if other, please explain: *

Excessive sweating while asleep *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Poor ability in school *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Please check all that apply *

Math
Science
Spelling
Writing
Reading

Falls asleep watching TV *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Wakes up at night *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Attention deficit *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Restless sleep *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Grinds teeth *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Frequent throat infections *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Frequent ear infections *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Feels sleepy and/or irritable during the day *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Difficult time listening and often interrupts *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Fidgets with hands or does not sit quietly *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Please check all that apply *

Muscular tics
Restless (wiggles) legs

Ever wets the bed *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Bluish color at night or during the day *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Nightmares and/or night terrors *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Exhibits any of the following: Rarely smiles, Feels sad, Feels depressed *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Please check all that apply *

Rarely Smiles
Feels sad
Feels Depressed

Speech problems *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Speech Questionnaire

Further Speech Assessment

Do you or do others have difficulty understanding your child's speech? *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Difficult to understand over the phone *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Uses grunts or screams more than words *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Lisp *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Hoarseness *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Nasal Speech *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Has frustration when attempting to speak *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Often uses words with only 1 or 2 syllables *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Seems winded when increasing volume *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Any difficulty in swallowing *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Do you think your child might have a stutter *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Any family history of a stutter? *

Tourette's Syndrome *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Family History of a speech or language disorder *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

Any speech therapy *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

If so, how long? *

Specific Articulation Questions

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

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

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

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

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

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

“sum” for “thumb”, “muhzer” for “mother” *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

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

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

“ship” for “chip”, “shoo shoo” for “choo choo” *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

“pasghetti” for “spaghetti”, “efelant” for “elephant”, “baksit” for “basket” *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

(Child changes position of a sound within a word)

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

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

(Child inserts “uh” into words)

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

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

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

“sue” for “shoe”, “sip” for “ship” “mezza” for “measure” *

Not Present: 0
Very Mild: 1
Mild: 2
Moderate: 3
Pronounced: 4
Severe: 5

(Child replaces a “sh” with an “s”)

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