Pediatric Airway & Myofunctional Screening Questionnaire
Check the symptoms your child experiences at night and during the day.
Patient Name
First Name
Last Name
Age
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Nighttime Sleep Symptoms
Which of the following nighttime sleep symptoms does your child experience? (Check all that apply)
Snoring
Mouth breathing during sleep
Restless sleep
Frequent waking
Night sweating
Bedwetting
Daytime Symptoms
Which of the following daytime symptoms does your child experience? (Check all that apply)
Mouth breathing when awake
Chronic nasal congestion
Dry mouth
Frequent throat clearing
Hoarse voice
Behavior and Cognitive Signs
Which of the following behavior and cognitive signs does your child exhibit? (Check all that apply)
Difficulty paying attention
Hyperactivity
Learning difficulties
Irritability or mood swings
Frequent headaches
SCORING GUIDE Consultation indicated for 3-5 checked (moderate risk), 6 and up (high risk)
Submit Screening
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