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Quality of Life Questionnaire
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Does your child have difficulty with breathing through the nose? (congestion, colds, ear aches, swollen tonsils, infections)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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Rate each statement by entering the appropriate numbers between 1 to 10. 1=Not at all 10=Extreme Difficulty
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Patient Forms
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Pediatric Sleep Questionnaire
Quality of Life Questionnaire
Financing Information
Airway & Sleep Group
11800 Sunrise Valley Dr.
Suite 200
Reston, VA 20191
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(571) 244-7329
Office Hours
Monday
7:30am – 3pm
Tuesday
7:30am – 3pm
Wednesday
7:30am – 3pm
Thursday
7:30am – 3pm
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