Dr. Greg Broyde BSc, DDS
Dr. Navdeep Dhaliwal BSc, DDS
526 Riverfront Ave SE
Calgary AB T2G 1E4
Ph: 403 263 9014

Sleep Disordered Breathing Questionnaire for Children

Please indicate to what degree your child exhibits any of the following symptoms using the scale of severity below.

The initial score should be evaluated and dated at first appointment and the follow-up score should be evaluated and dated after 3 months of treatment by the same person who filled out the initial assessment.

Not Present: 0 | Very Mild: 1 | Mild: 2 | Moderate: 3 | Pronounced: 4 | Severe: 5

If Speech Problems scores greater than 0, please continue to page 2.

Based on Sahin et al, 2009; and Urschitz et al, 2004; AM Thoracic Soc Stand, 1996; Attanasio et al, 2010



Speech Questionnaire for Children - Page 2

Not Present: 0 | Very Mild: 1 | Mild: 2 | Moderate: 3 | Pronounced: 4 | Severe: 5

Speech Assessment

Any family history of a stutter?

Specific Articulation Questions

Example: "hap" for "hat", "kif" for "kiss", "fum" for "thumb", or "bav" for "bath"

Example: "wabbit" for "rabbit", "yewo" for "yellow" "weg" for "leg", "pway" for "play" "wun" for "run"

Example: "tock" for "sock", "dump" for "jump", "pan" for "fan", "bat" for "fat"

Example: "sum" for "thumb", "muhzer" for "mother"

Example: "gog" for "dog", "cop" for "top", "boke" for "boat", "key" for "tea"

Example: "ship" for "chip", "shoo shoo" for "choo choo"

Example: "pasghetti" for "spaghetti", "efelant" for "elephant", "baksit" for "basket"

Example: "stuh-reet" for "street", "fuh-wog" for "frog", "buh-lue" for "blue", "puh-lease" for "please"

Example: "doat" for "goat", "tuhtie" for "cookie", "tup" for "cup", "hud" for "hug"

Example: "sue" for "shoe", "sip" for "ship","mezza" for "measure"


A follow-up score should be evaluated and dated after 3 months of treatment by the same person who filled out the initial assessment.