Sleep Disordered Breathing Questionnaire for Children

Patient's Name *

DOB *

Age *

Filled out by *

Relationship to Patient *

Pediatrician *

Dentist *

Please indicate to what degree your child exhibits any of the following symptoms using the scale of severity below.

The initial score should be evaluated and dated at first appointment and the follow-up score should be evaluated and dated after 3 months of treatment by the same person who filled out the initial assessment.

Not Present: 0 | Very Mild: 1 | Mild: 2 | Moderate: 3 | Pronounced: 4 | Severe: 5

If (30.) Speech Problems scores greater than 0, please continue to page 2.

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

Speech Questionnaire for Children - Page 2

Speech Assessment

1. Do you or do others have difficulty understand your child's speech?

2. Difficult to understand over the phone

3. Uses grunts or screams more than words

4. Lisp

5. Hoarseness

6. Nasal speech

7. Becomes frustrated when attempting to speak

8. Often uses words with only 1 or 2 syllables

9. Seems winded when increasing volume

10. Any difficulty in swallowing

11. Stutters

Any family history of a stutter?

Yes

12. Tourette's Syndrome

13. Family history of a speech or language disorder

14. Any speech therapy?

Specific Articulation Questions

1. Child replaces a "t, d, n, s, z, th or l" with a "p, b, m, w, f, or v"

Example: "hap" for "hat", "kif" for "kiss", "fum" for "thumb", or "bav" for "bath"

2. Child replaces an "r" with a "w" or an "L" with a "w" or a "y"

Example: "wabbit" for "rabbit", "yewo" for "yellow" "weg" for "leg", "pway" for "play" "wun" for "run"

3. Child replaces a "s, f, v, z, th, j, or h" with a consonant such as "p, b, t, d, k, g"

Example: "tock" for "sock", "dump" for "jump", "pan" for "fan", "bat" for "fat"

4. Child replaces a "p, b, m, w, th, f, or v" with a "t, d, s, z, n, or l"

Example: "sum" for "thumb", "muhzer" for "mother"

5. Child replaces a "t" or a "d" with "k" or "g"

Example: "gog" for "dog", "cop" for "top", "boke" for "boat", "key" for "tea"

6. Child replaces a "ch" or a "j" sound with a "sh, v, f, th, or s"

Example: "ship" for "chip", "shoo shoo" for "choo choo"

7. Child changes position of a sound within a word

Example: "pasghetti" for "spaghetti", "efelant" for "elephant", "baksit" for "basket"

8. Child inserts "uh" into words

Example: "stuh-reet" for "street", "fuh-wog" for "frog", "buh-lue" for "blue", "puh-lease" for "please"

9. Child replaces a "k" or a "g" with "t" or "d"

Example: "doat" for "goat", "tuhtie" for "cookie", "tup" for "cup", "hud" for "hug"

10. Child replaces a "sh" with an "s"

Example: "sue" for "shoe", "sip" for "ship","mezza" for "measure"

A follow-up score should be evaluated and dated after 3 months of treatment by the same person who filled out the initial assessment.

Date