www.viahealthgroup.com - Sleep, Breathing & Habit Questionnaire Form

Children and Adolescents

Sleep, Breathing & Habit Questionnaire
Patient’s Name:*

First NameLast Name
Age:
Date:*

MonthDayYear
Date
Please indicate if your child experiences or has experienced any of the symptoms below by using this scale to measure the severity of these symptoms.

0 - No Occurrence 1 - Occurs Rarely 2 - Occurs 2 to 4 times per week 3 - Occurs 5 to 7 times per week
1. Snoring

0123
15. Headaches

0123
2. Interrupted snoring where breathing stops

0123
16. Frequent throat infections

0123
3. Labored, difficult or loud breathing at night

0123
17. Seasonal allergies

0123
4. Gasping for air while sleeping

0123
18. Ear infections or history of ear infections

0123
5. Mouth breaths while sleeping

0123
19. Short attention span

0123
6. Mouth breathes during the day

0123
20. Trouble Focusing

0123
7. Restless sleep

0123
21. Difficulty listening/often interrupts

0123
8. Grinds teeth while sleeping

0123
22. Hyperactive

0123
9. Talks in sleep

0123
23. ADD/ADHD

0123
10. Excessive sweating while sleeping

0123
24. Sensory issues

0123
11. Wakes up at night

0123
25. Struggles in math at school

0123
12. Wets the bed (currently)

0123
26. Struggles in reading at school

0123
13. History of bedwetting

0123
27. Speech issue*

0123
14. Feels sleepy and/or irritable during the day

0123
28. Avoidance behavior towards food or certain types of food

0123
Speech Questionnaire - to be filled out only if #27 was indicated above
Please select all that apply to your child

Is it difficult to understand your child’s speech?Difficult to understand over the phone?Nasal speech?Hoarseness?Others have difficulty understanding speech?Gets frustrated when people can’t understand speech?Speech sounds abnormal?Sometimes omits consonants?Uses M, N, NG instead of P, V, S, Z sounds?Liquids and/or solids get into nasal area when eating or drinking?
Should be Empty:

Children and Adolescents

Speech Questionnaire - to be filled out only if #27 was indicated above