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Healthy Start Patient Form
Doctor's Name:*
Child's Name:*
Age:*
Your Name:*
Relationship to Patient:*
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:
Snore at all?*
Snore 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*
Hyperactive*
Mouth breathes during day*
Mouth breathes while sleeping*
Frequent headaches in morning*
Allergic symptoms*
Excessive sweating while asleep*
Talks in sleep*
Poor ability in school*
Falls asleep watching TV*
Wakes up at night*
Attention deficit*
Restless sleep*
Grinds teeth*
Frequent throat infections*
Feels sleepy and/or irritable during the day*
Have a hard time listening and often interrupts*
Fidgets with hands or does not sit quietly*
Ever wets the bed*
Bluish color at night or during the day*
Speech Problems*
(If yes, fill out speech questionnaire below)
Was your reason for coming to this doctor for sleep or dental issues:*
Speech Questionnaire
To be filled out only if #27 was indicated above
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 instead of P, F, V, S, Z sounds*
Hoarseness*
Lisp*
If taking speech therapy, for how long?*

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Healthy Start Patient Form

Sleep Disordered Breathing Questionnaire for Children

Does your child:

Speech Questionnaire

Please check all that apply to your child