Quality of Life Questionnaire

Does your child have difficulty with breathing through the nose? (congestion, colds, ear aches, swollen tonsils, infections)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with keeping lips together at rest? (open mouth, lips apart at rest, chapped lips)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with chewing and swallowing? (uses face muscles, sloppy, noisy, quickly, drooling, tongue tie)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with sitting and standing with good posture? (slouching, forward head, aches or pains)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with eating and nutrition? (picky, difficulty chewing, not nutritious, digestive issues)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with daytime breathing? (Asthma, allergies to food, pollen, animals, toxins, parasites)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with getting a good night's sleep? (restless, snoring, messy bed, awakening, accidents)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with breathing while sleeping? (snoring, heavy breathing, open mouth)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with teeth grinding? (bruxism, clenching, nighttime/daytime)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with body aches or pain? (jaw aches, headaches, migraines, neck or back pain)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
Does your child have difficulty with behavioral issues at home or in school? (attention, learning, hyper, sleepy, spectrum)
Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
This field is for validation purposes and should be left unchanged.

Airway & Sleep Group

11800 Sunrise Valley Dr.
Suite 200
Reston, VA 20191

Office Hours

Monday
7am – 4pm
Tuesday
7am – 4pm
Wednesday
7am – 4pm
Thursday
7am – 4pm
Friday
7am – 4pm
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