Diagnostic System

Patient Name*

City*

State*

Gender*

Age*

Current Dentist*

Email*

Phone*

Sleep Disordered Breathing Questionnaire for Children Earl O. Bergersen, DDS, MSD

The initial column should be filled out at first appointment, and the follow up column should be completed after 3 months of treatment. Please identify the following symptoms your child exhibits with the scale indicating severity of symptoms.

0 Not Present 1 or 2 Mild 3 Moderate 4-5 Pronounced

Does your child:

INITAL

Snore at all?

Snore only infrequently (1 night/week)

Snore fairly often (2-4 nights/week)

Snore habitually (5-7 nights/week)

Have labored, difficult, loud breathing at night

Have interrupted snoring where breathing stops for 4 or more seconds

Have stoppage of breathing more than 2 times in an hour

Hyperactive

Mouth breathes during day

10.

Mouth breathes while sleeping

11.

Frequent headaches in morning

12.

Allergic symptoms

13.

Excessive sweating while asleep

INITAL

14.

Talks in sleep

15.

Poor ability in school

16.

Falls asleep watching TV

17.

Wakes up at night

18.

Attention deficit

19.

Restless sleep

20.

Grinds teeth

21.

Frequent throat infections

22.

Feels sleepy and/or irritable during the day

23.

Have a hard time listening and often interrupts

24.

Fidgets with hands or does not sit quietly

25.

Ever wets the bed

26.

Bluish color at night or during the day

27.

Speech Problems *

*If yes, provide parent speech questionnaire

Was your reason for coming to this doctor for sleep or dental issues:

Based on Sahin et al, 2009; and Urschitz et al, 2004; AM Thoracic Soc Stand, 1996; Attanasio et al, 2010

Speech Questionnaire

To be filled out only if #27 was indicated above

Please check all that apply to your child:

INITAL

28.

Is it difficult to understand your child�s speech

29.

Difficult to understand over the phone?

30.

Nasal speech?

31.

Speech sounds abnormal?

32.

Others have difficulty understanding speech?

33.

Gets frustrated when people can�t understand speech?

INITAL

34.

Sometimes omits consonants

35.

Uses M, N, NG instead of P, F, V, S, Z sounds

36.

Hoarseness

37.

Lisp

38.

Any speech therapy?

How Long?

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