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Children's Airway Questionnaire

Could your child’s behavior be linked to airway restriction?

 

If you answer “yes” to eight or more of the following questions, you should consider referring your child for sleep evaluation.

If your child qualifies for treatment, one of the Elite Dental team members will contact you as soon as possible.

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While sleeping, does your child...

Regularly snore? *
Yes
No
Don't Know
Appear to be a restless sleeper? *
Yes
No
Don't Know
Snore loudly? *
Yes
No
Don't Know
Kick out* *
Yes
No
Don't Know
Have “heavy” or loud breathing? *
Yes
No
Don't Know
Have trouble breathing or struggle to breathe?* *
Yes
No
Don't Know
Have nightmares? *
Yes
No
Don't Know
Scream in their sleep? *
Yes
No
Don't Know
Grind their teeth? *
Yes
No
Don't Know

Have you ever...

Seen your child stop breathing during the night? *
Yes
No
Don't Know

Does your child...

Tend to breathe through the mouth during the day? *
Yes
No
Don't Know
Have a dry mouth on waking up in the morning? *
Yes
No
Don't Know
Occasionally wet the bed? *
Yes
No
Don't Know
Wake up feeling un-refreshed in the morning? *
Yes
No
Don't Know
Have a problem with sleepiness during the day? *
Yes
No
Don't Know
Is it hard to wake your child up in the morning? *
Yes
No
Don't Know
Did your child stop growing at a normal rate at any time since birth? *
Yes
No
Don't Know
Has a teacher or other supervisor commented that your child appears sleepy during the day? *
Yes
No
Don't Know
Does your child wake up with headaches in the morning? *
Yes
No
Don't Know
Is your child overweight? *
Yes
No
Don't Know

This child often...

Does not seem to listen when spoken to directly *
Yes
No
Don't Know
Has difficulty organizing tasks *
Yes
No
Don't Know
Is easily distracted by extraneous stimuli *
Yes
No
Don't Know
Is “on the go” or often acts as if “driven by a motor” *
Yes
No
Don't Know
Fidgets with hands or feet or squirms in seat *
Yes
No
Don't Know
Interrupts or intrudes on others (e.g. butts into conversations or games) *
Yes
No
Don't Know

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