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OSA Questionnaire

How to complete this Questionnaire

For each question below please select the number that best describes how often each symptom or problem has occurred during the last 4 weeks.
Please select only one number per question.

During the past 4 weeks, how often has your child had…

1. 
Loud snoring?

2. 
Breath holding spells or pauses in breathing at night?

3. 
Choking or made gasping sounds while asleep?

4. 
Mouth breathing because of a blocked nose?

5. 
Frequent colds or a runny nose?

6. 
Nasal discharge or a runny nose?

7. 
Aggressive or hyperactive behaviour?

8. 
Discipline problems?

9. 
Excessive daytime sleepiness?

10. 
Poor attention span or concentration?

11. 
Breathing problems during sleep that made you worried that they were not getting enough air?

First Name
Last Name
Email
Phone
  • 0
    None of the time
  • 1
    Some of the time
  • 2
    Most of the time
  • 3
    All of the time
Excel ENT Surgeons

Contact

Excel ENT Surgeons phone

PHONE

(03) 9088 8222

Excel ENT Surgeons fax

FAX

(03) 9088 8223

Excel ENT Surgeons email

EMAIL

admin@excelentsurgeons.com.au

Phone (03) 9088 8222
EMAIL admin@excelentsurgeons.com.au
FAX (03) 9088 8223

CONSULTING LOCATIONS

Excel Camberwell
607–609 Riversdale Road,
Camberwell VIC 3124

Offspring Paediatrics
614 Glenferrie Road,
Hawthorn VIC 3122