Pediatric Airway Evaluation
First Name
MI
Last Name
*
Birthdate:
While sleeping does your child......
Snore more than half the time?
No
Yes
I don't know
Always snore?
No
Yes
I don't know
Snore loudly?
No
Yes
I don't know
Have 'heavy' or loud breathing?
No
Yes
I don't know
Have trouble breathing or struggle to breathe?
No
Yes
I don't know
Have you ever seen your child stop breathing while sleeping?
No
Yes
I don't know
Does your child.....
Tend to breathe through the mouth during the day?
No
Yes
I don't know
Have a dry mouth on waking up in the morning?
No
Yes
Occasionally wet the bed?
No
Yes
I don't know
Wake up feeling un-refreshed in the morning?
No
Yes
I don't know
Have problems with sleepiness during the day?
No
Yes
I don't know
Has a teacher or other supervisor commented that your child appears sleepy during the day?
No
Yes
I don't know
Is it hard to wake your child up in the morning?
No
Yes
I don't know
Does your child wake up with headaches in the morning?
No
Yes
I don't know
Did your child stop growing at a normal rate at any time since birth?
No
Yes
I don't know
Is your child overweight?
No
Yes
I don't know
This child often.....
Does not seem to listen when spoken to directly
No
Yes
I don't know
Has difficulty organizing tasks
No
Yes
I don't know
Is easily distracted by extraneous stimuli
No
Yes
I don't know
Fidgets with hands or feet or squirms in seat
No
Yes
I don't know
Is 'on the go' or often acts as if 'driven by a motor'
No
Yes
I don't know
Interrupts or intrudes on others (e.g. butts into conversations or games)
No
Yes
I don't know
Total number of
YES
responses:
If
eight or more
statements are answered with '
yes
', consider referring for sleep evaluation.
CHERVINE ET AL, PEDIATRIC SLEEP QUESTIONNAIRE: VALIDITY AND RELIABILITY OF SCALES FOR SLEEP DISORDERED BREATHING, SNORING, SLEEPINESS, AND BEHAVIORAL PROBLEMS, SLEEP MEDICINE 2000; 1:21-32