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?
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