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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
  • 0
    None of the time
  • 1
    Some of the time
  • 2
    Most of the time
  • 3
    All of the time
Excel ENT Surgeons



(03) 9088 8222

Excel ENT Surgeons fax


(03) 9088 8223


Excel Camberwell
607–609 Riversdale Road,
Camberwell VIC 3124

Offspring Paediatrics
614 Glenferrie Road,
Hawthorn VIC 3122