Clone of HEALIOX 2.0 - Paediatric Sleep Health Questionnaire

1
Your (Parent / Carer) Name
First Name
Last Name
2
During the past 4 weeks, how often has your child had the following
None of the time
Some of the time
Most of the time
All of the time
Loud snoring
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Breath-holding or pauses at night
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Choking or gasping
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Mouth breathing because of a blocked nose
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Breathing problems in sleep / worried they are not getting enough air in at night
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Loud snoring
Breath-holding or pauses at night
Choking or gasping
Mouth breathing because of a blocked nose
Breathing problems in sleep / worried they are not getting enough air in at night
None of the time
Row 0, Column 0
Some of the time
Row 0, Column 1
Most of the time
Row 0, Column 2
All of the time
Row 0, Column 3
None of the time
Row 1, Column 0
Some of the time
Row 1, Column 1
Most of the time
Row 1, Column 2
All of the time
Row 1, Column 3
None of the time
Row 2, Column 0
Some of the time
Row 2, Column 1
Most of the time
Row 2, Column 2
All of the time
Row 2, Column 3
None of the time
Row 3, Column 0
Some of the time
Row 3, Column 1
Most of the time
Row 3, Column 2
All of the time
Row 3, Column 3
None of the time
Row 4, Column 0
Some of the time
Row 4, Column 1
Most of the time
Row 4, Column 2
All of the time
Row 4, Column 3
1 of 5
3
OSA-5 Score Total:> 5 indicates higher risk for Obstructive Sleep Apnoea
4
Image Field
5
Image Field
6
Image Field
7
Would you like Healiox X Sleep Kids United X Melbourne ENT Group to contact you for more information about multi-disciplinary sleep assessments options for your child?* This field is required.We will not contact you without your consent
YESNO
8
Your EmailYou answered 'yes' that you would like Healiox / Sleep Kids United to reach out to you. We treat your information and that of your child in accordance with all privacy principles and do not share information with third parties
example@example.com
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