Child Health Questionnaire

Day Time Symptoms

During the day, does your child:
1. Breathe with their mouth open? YesNo
2. Make noises when breathing? YesNo
3. Have trouble sitting still? YesNo
4. Have problems with learning, attention or concentration? YesNo
5. Have any behavioural concerns? YesNo
6. Attend speech pathology? YesNo
7. Have trouble chewing meat or other hard foods? YesNo
8. Frequently get tired? YesNo

Night Time Symptoms

While sleeping, does your child:
1. Have trouble going to sleep? YesNo
2. Have their mouth open? YesNo
3. Snore? YesNo
4. Wet the bed? YesNo
5. Grind their teeth? YesNo
6. Toss and turn / kick the covers off? YesNo
7. Tilt their head back? YesNo
8. Have frequent nightmares/terrors? YesNo
9. Sweat at night? YesNo
10. Wake up frequently? YesNo
11. Have trouble waking up? YesNo
12. Have abnormal sleep issues? YesNo

History

As a baby, was your child:
1. Born premature? If so, list how many weeks below. YesNo
2. Breast fed? If so, list how many months below. YesNo
3. Hard to breast feed? YesNo
4. Prone to ear infections? YesNo
5. Use a dummy or pacifier? If so, please write until what age below. YesNo
6. Suck their finger or thumb? If so, list which finger/thumb and till what age below. YesNo

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