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  • Healthy Start Patient Form

  • Sleep Disordered Breathing Questionnaire for Children

    The initial column should be filled out at first appointment. Please identify the following symptoms your child exhibits with the scale indicating severity of symptoms.

    Not Present: 0
    Mild: 1-2
    Moderate: 3
    Pronounced: 4-5
  • Does your child:

  • (If yes, fill out speech questionnaire below)
  • Speech Questionnaire

    To be filled out only if #27 was indicated above
  • Please check all that apply to your child

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