You can always press Enter⏎ to continue
Youth Sleep Apnea Assessment
Please fill out and submit this encrypted form.
9
Questions
START
Encrypted
Secure Form
1
Name
*
This field is required.
Please enter your name
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Phone Number
*
This field is required.
Let us know your number so we can follow up with your after the assessment
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
3
Patient Name
*
This field is required.
Please enter your child's name
First Name
Last Name
Previous
Next
Submit
Press
Enter
4
Date of Birth
*
This field is required.
Please enter your child's date of birth
-
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
5
While Sleeping Does Your Child...
*
This field is required.
Yes
No
Don't Know
Snore more than half the time?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Always Snore?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Snore Loudly?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Have 'heavy' or loud breathing?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Have trouble breathing or struggle to breathe?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Snore more than half the time?
Always Snore?
Snore Loudly?
Have 'heavy' or loud breathing?
Have trouble breathing or struggle to breathe?
Yes
Row 0, Column 0
No
Row 0, Column 1
Don't Know
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Don't Know
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Don't Know
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Don't Know
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Don't Know
Row 4, Column 2
1
of 5
Previous
Next
Submit
Press
Enter
6
Does Your Child...
*
This field is required.
Yes
No
Don't Know
Tend to breathe through the mouth during the day?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Have a dry mouth on waking up in the morning?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Occasionally wet the bed?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Have a problem with sleepiness during the day?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Have a teacher or other supervisor commented that your child appears sleeping during the day?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Is it hard to wake your child up in the morning?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Wake up with headaches in the morning?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Tend to breathe through the mouth during the day?
Have a dry mouth on waking up in the morning?
Occasionally wet the bed?
Have a problem with sleepiness during the day?
Have a teacher or other supervisor commented that your child appears sleeping during the day?
Is it hard to wake your child up in the morning?
Wake up with headaches in the morning?
Yes
Row 0, Column 0
No
Row 0, Column 1
Don't Know
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Don't Know
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Don't Know
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Don't Know
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Don't Know
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Don't Know
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Don't Know
Row 6, Column 2
1
of 7
Previous
Next
Submit
Press
Enter
7
This Child Often...
*
This field is required.
Yes
No
Don't Know
Does not seem to listen when spoken to directly
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Has difficulty organizing tasks
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Is easily distracted by extraneous stimuli
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Fidgets with hands or feet or squirms in seat
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Is 'on the go' or often acts as if 'driven by motor'
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Interrupts or intrudes on others (e.g. butts into conversations or games)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Does not seem to listen when spoken to directly
Has difficulty organizing tasks
Is easily distracted by extraneous stimuli
Fidgets with hands or feet or squirms in seat
Is 'on the go' or often acts as if 'driven by motor'
Interrupts or intrudes on others (e.g. butts into conversations or games)
Yes
Row 0, Column 0
No
Row 0, Column 1
Don't Know
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Don't Know
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Don't Know
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Don't Know
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Don't Know
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Don't Know
Row 5, Column 2
1
of 6
Previous
Next
Submit
Press
Enter
8
*
This field is required.
Yes
No
Don't Know
Have you ever seen your child stop breathing during the night?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Did your child stop growing at a normal rate since time of birth?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Is your child overweight?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Have you ever seen your child stop breathing during the night?
Did your child stop growing at a normal rate since time of birth?
Is your child overweight?
Yes
Row 0, Column 0
No
Row 0, Column 1
Don't Know
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Don't Know
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Don't Know
Row 2, Column 2
1
of 3
Previous
Next
Submit
Press
Enter
9
*
This field is required.
Please Read the Following Terms & Conditions Before Submitting
Previous
Next
Submit
Press
Enter
10
Calculation
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
10
See All
Go Back
Submit
