Considering how severe the problem is when your child experiences it & how often it has happened over the last 4 weeks for your child, please rate each item below on how ‘bad’ it is by circling the number that corresponds with how you feel using this scale:
No problem Very mild problem Mild or slight problem Moderate problem Severe problem Problem as bad as it can be
Snoring loudly during sleep
0
1
2
3
4
5
Irregular or stopped breathing (apnoea) during sleep
0
1
2
3
4
5
Daytime sleepiness
0
1
2
3
4
5
Noisy breathing during the day
0
1
2
3
4
5
Breathing through the mouth during the day
0
1
2
3
4
5
Problems with poor appetite or poor eating habits (choking on food etc)
0
1
2
3
4
5
Frequent earache or ear infections
0
1
2
3
4
5
Repeated short term throat infections that last less than 2 weeks
0
1
2
3
4
5
Constant or chronic throat infections that last more than 2 weeks
0
1
2
3
4
5
Many phone calls to the GP
0
1
2
3
4
5
Many visits to the family doctor or an Emergency department
0
1
2
3
4
5
Taking antibiotics over & over for less than 2 weeks at a time
0
1
2
3
4
5
Taking antibiotics for more than 2 weeks straight
0
1
2
3
4
5
Missing school days due to sore throats
0
1
2
3
4
5
TOTAL:
Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating: Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating: Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating: Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating: Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating: Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating: Please enter any further important symptoms that occur as a result of your child’s throat problems that we have missed from the list above and give each a rating:
0 1 2 3 4 5
0 1 2 3 4 5
0 1 2 3 4 5
TOTAL:
GRAND TOTAL