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

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Doctor

Child's Name

Age

Date

Filled Out By

Relationship To Patient

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 - 2 Mild 3 Moderate 4 - 5 Pronounced

Does Your Child:

Initial

Follow Up

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

Mouth breathes while sleeping

Frequent headaches in morning

Allergic symptoms

Excessive sweating while asleep

Talks in sleep

Initial

Follow Up

Poor ability in school

Falls asleep watching TV

Wakes up at night

Attention deficit

Restless sleep

Grinds teeth

Frequent throat infections

Feels sleepy and/or irritable during the day

Have a hard time listening and often interrupts

Fidgets with hands or does not sit quietly

Ever wets the bed

Bluish color at night or during the day

Speech Problems*
*If yes, fill out 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:

Patient Name Validation

Sleep Disordered Breathing Questionnaire for ChildrenEarl O. Bergersen, DDS, MSD

Speech QuestionnaireTo be filled out only if #27 was indicated above

Signature

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

Speech Questionnaire
To be filled out only if #27 was indicated above