OSA Questionnaire During the past 4 weeks, how often has your child had… 1. Loud snoring? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 2. Breath holding spells or pauses in breathing at night? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 3. Choking or made gasping sounds while asleep? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 4. Mouth breathing because of a blocked nose? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 5. Frequent colds or a runny nose? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 6. Nasal discharge or a runny nose? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 7. Aggressive or hyperactive behaviour? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 8. Discipline problems? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 9. Excessive daytime sleepiness? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 10. Poor attention span or concentration? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time 11. Breathing problems during sleep that made you worried that they were not getting enough air? 0 - None of the time 1 - Some of the time 2 - Most of the time 3 - All of the time First Name Last Name Email Phone Time's up
SNOT 22 Questionnaire 1. Need to blow nose 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 2. Sneezing 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 3. Runny Nose 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 4. Cough 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 5. Post-nasal discharge (dripping at the back of your nose) 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 6. Thick Nasal Discharge 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 7. Ear Fullness 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 8. Dizziness 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 9. Ear Pain 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 10. Facial pain/Pressure 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 11. Difficulty falling asleep 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 12. Wake up at night 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 13. Lack of a good night's sleep 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 14. Wake up tired 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 15. Fatigue 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 16. Reduced productivity 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 17. Reduced concentration 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 18. Frustrated/restless/irritable 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 19. Sad 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 20. Embarrassed 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 21. Sense of taste/smell 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be 22. Blockage/congestion of nose 0 - No problem 1 - Very Mild problem 2 - Mild or slight problem 3 - Moderate problem 4 - Severe problem 5 - Problem as bad as it can be First Name Last Name Email Phone Time's up
DGK Test Quiz 1. Nasal congestion or stuffiness Not a problem Very mild problem Moderate problem Fairly bad problem Severe problem 2. Nasal blockage or obstruction Not a problem Very mild problem Moderate problem Fairly bad problem Severe problem 3. Trouble breathing through my nose Not a problem Very mild problem Moderate problem Fairly bad problem Severe problem 4. Trouble sleeping Not a problem Very mild problem Moderate problem Fairly bad problem Severe problem 5. Unable to get enough air through my nose during exercise or exertion Not a problem Very mild problem Moderate problem Fairly bad problem Severe problem First Name Last Name Email Phone Time's up
