Clone of HEALIOX 2.0 - Paediatric Sleep Health Questionnaire

1

Your name (Parent / Carer)

First Name

Last Name

2

While sleeping does your child…* This field is required.(Please answer every question)

3

While sleeping does your child Snore more than half the time?* This field is required.

Yes

No

Don't know

4

Q1 YES

5

Q1NO

6

While sleeping does your child always snore?* This field is required.

Yes

No

I don't know

7

Q2 YES

8

Q2 NO

9

While sleeping does your child snore loudly?* This field is required.

Yes

No

Don't know

10

Q3 YES

11

Q3 NO

12

While sleeping does your child have “heavy” or loud breathing?* This field is required.

Yes

No

Don't know

13

Q4 YES

14

Q4 NO

15

While sleeping does your child have trouble breathing or struggle to breathe?* This field is required.

Yes

No

Don't know

16

Q5 NO

17

Q5 yes

18

Have you ever seen your child stop breathing?

Yes

No

Don't know

19

Q6 yes

20

Q6 no

21

Does your child tend to breathe through the mouth during the day?

Yes

No

Don't know

22

Q7 no

23

Q7 yes

24

Does your child have a dry mouth on waking up in the morning?

Yes

No

Don't know

25

Q8 no

26

Q8 yes

27

Does your child occasionally wet the bed ?

Yes

No

Don't know

28

Q9 yes

29

Q9 no

30

Does your child wake up feeling un-refreshed in the morning ?

Yes

No

Don't know

31

Q10 no

32

Q10 yes

33

Does your child have a problem with sleepiness during the day ?

Yes

No

Don't know

34

Q11 yes

35

Q11 no

36

Has a teacher or other supervisor commented that your child appears sleepy during the day ?

Yes

No

Don't know

37

Q12 no

38

Q12 yes

39

Is it hard to wake your child up in the morning ?

Yes

No

Don't know

40

Q13 yes

41

Q13 no

42

Does your child wake up with headaches in the morning ?

Yes

No

Don't know

43

Q14 no

44

Q14 yes

45

Did your child stop growing at a normal rate at any time since birth?

Yes

No

Don't know

46

Q15 no

47

Q15 yes

48

Is your child overweight ?

Yes

No

Don't know

49

Q16 yes

50

Q16 no

51

This child often does not seem to listen when spoken to directly

Yes

No

Don't know

52

Q17 no

53

Q17 yes

54

This child often has difficulty organising tasks

Yes

No

Don't know

55

Q18 yes

56

Q18 no

57

This child often is easily distracted by extraneous stimuli

Yes

No

Don't know

58

Q19 no

59

Q19 yes

60

This child often fidgets with hands or feet or squirms in seat

Yes

No

Don't know

61

Q20 yes

62

Q20 no

63

This child often is “on the go” or often acts as if “driven by a motor”

Yes

No

Don't know

64

Q21 no

65

Q21 yes

66

This child often Interrupts or intrudes on others (e.g. butts into conversations or games)

Yes

No

Don't know

67

Q22 yes

68

Q22 no

69

YES

70

NO

71

Have you ever…* This field is required.(Please answer every question)

Yes

No

Don’t Know

Seen your child stop breathing

Yes

No

Don’t Know

74

YES AND NO> 0.33 predicts risk of moderate-severe Obstructive Sleep Apnoea on PSG

75

PSQ Total ScoreA Total score > 0.33 has been shown to predict moderate–severe Obstructive Sleep Apnoea..

76

77

78

79

Would you like the team at Healiox X Sleep Kids United X Melbourne ENT Group to contact you regarding further information about multi-disciplinary sleep assessment options?* This field is required.We will not contact you without your consent

YESNO

80

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

Email Verified

The verification code has been sent to some@email.com
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