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 |