form test page

Patient's Questionnaire

Sleep Disordered Breathing Questionnaire for Children

The initial column should be filled out at first appointment, and the follow up column should be completed after 3 months of treatment. Please identify the following symptoms your child exhibits with the scale indicating severity of symptoms.

0 – Not Present; 1 – 2 Mild; 3 Moderate; 4 - 5 Pronounced

Does your child:

Pre Treatment
Follow up
Treatment

*If yes, provide parent speech questionnaire


Speech Questionnaire

Please check all that apply to your child:

Pre Treatment
Follow up
Treatment