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Pediatric Airway Assessment

This screening form may help identify patients at increased risk for sleep-related breathing disorders (e.g., obstructive sleep apnea) and/or breathing complications when undergoing sedation or general anesthesia. Such patients may benefit from referral to a medical professional for further evaluation and management.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Part I. General History
YesNo
How many weeks early?*
YesNo
Describe*
Does your child have any history of
YesNo
Describe*
YesNo
Describe*
YesNo
Describe*
YesNo
Describe*
Part II. Daytime indicators

Does your child often:
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
Part III. Sleep History
GoodFairPoor
How many hours does your child sleep on average during a 24-hour period?
Does your child
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
YesNoDo not know
Signature of parent/guardian *

Clear
Relationship to child*
Date*

MonthDayYear
Date
IIIIIIIV
01234
YesNo
Comments
Reference:

1. Friedman M, Tanyeri H, La Rosa M, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope 1999;109(12):1901-7.
Images reprinted and adapted with permission of John Wiley and Sons.
Copyright © 1999. Friedman M, Tanyeri H, La Rosa M, Landsberg R, et al. Laryngoscope 1999;109(12):1901-7.
Available at: “https://onlinelibrary.wiley.com/doi/abs/10.1097/00005537-199912000-000028”.
Laryngoscope is published for the American Laryngological Rhinological and Otological Society by John Wiley and Sons Ltd.
Should be Empty:

Pediatric Airway Assessment

Part I. General History

Does your child have any history of

Part II. Daytime indicators

Part III. Sleep History

Does your child