AirwayZ Inventory

Adolescent Screening Questionnaire

AirwayZ Airway Health Inventory — Adolescent (Ages 12–17)
AirwayZ
Instrument 3 · Adolescent · Ages 12–17
AirwayZ
Airway Health Inventory
Adolescent
Ages 12–17 · Caregiver and Self-Report
TreatOrigin Productions, LLC
Name
Age / Grade
Date
Caregiver
Pediatrician
Dentist
Caregiver column · What you observe from outside
Self-report column · What the adolescent experiences directly
How to complete
This form has two columns for most questions: one for the caregiver observations and one for the adolescent self-report. Both should be completed where possible. The two perspectives together are more informative than either alone. There are no right or wrong answers. This form is a starting point for conversation with a provider, not a diagnosis.
Severity scale
0 Not present   1 Mild   2 Mild-moderate   3 Moderate
4 Moderate-pronounced   5 Pronounced

Initial column = today  ·  F/U = after 3 months of care
A note on adolescence: Many symptoms of sleep-disordered breathing in teenagers, including fatigue, mood changes, difficulty concentrating, weight changes, and excessive sleep, closely resemble the normal experience of puberty. This overlap is well-documented and contributes to significant underdiagnosis in this age group. When these symptoms are persistent, pronounced, or affecting daily functioning, they warrant evaluation regardless of age.
Section 1 · Nighttime & Sleep
Snoring frequency · Caregiver: mark what you observe. Adolescent: mark what you are aware of.
Never ~1× / week 2–4× / week Most nights Every night
Does the adolescent snore?
Does the adolescent have labored, loud, or heavy breathing during sleep?
During sleep · Severity: 0–5  ·  Blue = Caregiver  ·  Amber = Self-report
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Sleep with mouth open?
0
1
2
3
4
5
0
1
2
3
4
5
Sweat heavily or seem uncomfortably warm during sleep?
0
1
2
3
4
5
0
1
2
3
4
5
Move excessively, kick, or seem restless throughout the night?
0
1
2
3
4
5
0
1
2
3
4
5
Sleep with neck hyperextended or head tilted noticeably far back?
0
1
2
3
4
5
0
1
2
3
4
5
Have night terrors, sleepwalk, or seem awake but unresponsive during the night? Parasomnias are associated with sleep fragmentation and sleep-disordered breathing in adolescents.
0
1
2
3
4
5
0
1
2
3
4
5
Grind or clench teeth during sleep?
0
1
2
3
4
5
0
1
2
3
4
5
Wake frequently during the night without an obvious cause?
0
1
2
3
4
5
0
1
2
3
4
5
Feel very difficult to wake in the morning, seeming unrefreshed despite adequate sleep hours?
0
1
2
3
4
5
0
1
2
3
4
5
Wake with headaches, before getting out of bed?
0
1
2
3
4
5
0
1
2
3
4
5
Have a dry mouth upon waking?
0
1
2
3
4
5
0
1
2
3
4
5
Sleep in a way that feels better on their side or stomach than on their back? Positional preference during sleep can reflect airway patency differences by position.
0
1
2
3
4
5
0
1
2
3
4
5
Observed or experienced during sleep YesNoNot sure
Have you (caregiver) or has the adolescent ever observed or experienced choking or gasping sounds during sleep?
Has breathing appeared to stop, or has the adolescent woken suddenly with a sensation of not being able to breathe?
Has the adolescent's snoring been interrupted: cutting off abruptly before resuming?
If yes to any above, please describe what was observed or experienced:
Section 2 · Daytime Symptoms
During the day · Severity: 0–5  ·  Blue = Caregiver  ·  Amber = Self-report
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Seem excessively tired or sleepy during the day, beyond what activity level would explain?
0
1
2
3
4
5
0
1
2
3
4
5
Fall asleep in class, during quiet activities, or in the car?
0
1
2
3
4
5
0
1
2
3
4
5
Have difficulty concentrating, staying focused, or sustaining attention on tasks?
0
1
2
3
4
5
0
1
2
3
4
5
Have recurring headaches at least once a month, apart from morning waking headaches?
0
1
2
3
4
5
0
1
2
3
4
5
Have chronic nasal congestion or consistent difficulty breathing through the nose?
0
1
2
3
4
5
0
1
2
3
4
5
Have allergic symptoms: year-round nasal symptoms, runny eyes, skin reactions, or eczema?
0
1
2
3
4
5
0
1
2
3
4
5
Have frequent acid reflux, heartburn, or need to frequently clear the throat?
0
1
2
3
4
5
0
1
2
3
4
5
Have frequent ear infections, fluid in the ears, or recurring hearing concerns?
0
1
2
3
4
5
0
1
2
3
4
5
YesNoNot sure
Has the adolescent ever had a failed hearing screen or been evaluated for hearing loss? Chronic upper airway obstruction and adenoid hypertrophy can contribute to conductive hearing loss.
Has a teacher, coach, or counselor expressed concern about the adolescent's attention, energy, or functioning?
Section 3 · Mood, Mental Health & Social Impact
Adolescent OSA often presents as mood and mental health concerns rather than obvious sleepiness. Both perspectives matter here. · Blue = Caregiver  ·  Amber = Self-report
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Have persistent low mood, sadness, or loss of interest in activities they used to enjoy? Depression is significantly associated with OSA in adolescents, particularly in girls and in those aged 12 and older.
0
1
2
3
4
5
0
1
2
3
4
5
Have anxiety, excessive worry, or a sense of dread that seems disproportionate to circumstances?
0
1
2
3
4
5
0
1
2
3
4
5
Have persistent irritability, moodiness, or emotional outbursts that seem beyond typical adolescent adjustment?
0
1
2
3
4
5
0
1
2
3
4
5
Seem to have low self-esteem or a poor sense of confidence in their abilities or appearance? Adolescents at higher risk for OSA show significantly lower self-esteem compared to peers without airway concerns.
0
1
2
3
4
5
0
1
2
3
4
5
Withdraw socially, pull away from friends or family, or seem less engaged with life?
0
1
2
3
4
5
0
1
2
3
4
5
Have difficulty managing emotions, regulating behavior, or engaging in age-appropriate social situations?
0
1
2
3
4
5
0
1
2
3
4
5
YesNoNot sure
Has the adolescent received or been referred for mental health support, counseling, or therapy?
Section 4 · Academic & Physical Performance
Self-report focus · How is fatigue or sleep affecting daily functioning?
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Underperform academically relative to apparent effort and intelligence? Academic problems are a specific item in the validated teen STOP-Bang instrument.
0
1
2
3
4
5
0
1
2
3
4
5
Have a noticeable decline in grades, motivation, or engagement with school over the past year?
0
1
2
3
4
5
0
1
2
3
4
5
Notice that fatigue or sleepiness is affecting sports performance, training, or physical activities?
0
1
2
3
4
5
0
1
2
3
4
5
YesNoNot sure
Does the adolescent rely on caffeine, energy drinks, or stimulants to get through the day? Compensatory caffeine or stimulant use is a behavioral marker for chronic fatigue from disrupted sleep.
If the adolescent drives, has drowsiness ever been a concern while driving? For ages 16 and above. Drowsy driving is a recognized safety risk in adolescents with untreated sleep disorders.
Section 5 · Oral, Jaw & Structural
Primarily self-report · Severity: 0–5
Does the adolescent... 012 345 F/U
Rest with mouth open at baseline: lips apart, tongue low, jaw dropped when relaxed and not speaking or eating? Resting oral posture reflects the default position of the orofacial structures, distinct from sleep or exercise mouth breathing.
0
1
2
3
4
5
Breathe through the mouth during the day as a habitual pattern?
0
1
2
3
4
5
Chew with mouth open, or find it difficult to chew comfortably with lips closed?
0
1
2
3
4
5
Have jaw pain, clicking, popping, or locking?
0
1
2
3
4
5
Clench or grind teeth during the day?
0
1
2
3
4
5
Have jaw stiffness or discomfort upon waking in the morning?
0
1
2
3
4
5
Have chronic neck pain, tension headaches, or persistent head and neck discomfort?
0
1
2
3
4
5
Have poor posture or a forward head position, or has anyone commented on this? Forward head posture is biomechanically linked to reduced pharyngeal airway tone and habitual mouth breathing.
0
1
2
3
4
5
Seem clumsy, poorly coordinated, or have had difficulty with activities requiring balance?
0
1
2
3
4
5
Tongue, lip, and oral posture · Self-report
Roof Bottom Unsure
Where does your tongue rest when your mouth is relaxed and closed? Correct resting posture: tongue flat against the palate, lips together, teeth lightly touching.
YesNoNot sure
Can the adolescent keep lips together comfortably at rest, without strain? Lip incompetence is associated with habitual mouth breathing and altered orofacial development.
Has a dentist noted a narrow jaw, high palate, crowded teeth, crossbite, or open bite?
Has the adolescent had orthodontic treatment, or had teeth extracted for crowding? A history of extractions for crowding may indicate a structurally narrow arch and is a craniofacial risk factor for airway concerns.
Have the tonsils or adenoids been evaluated or removed?
Has the adolescent been evaluated for or diagnosed with tongue tie (ankyloglossia)? Short lingual frenulum is an independent risk factor for sleep-disordered breathing and myofunctional dysfunction in this age group.
Section 6 · Medical History & Risk Flags
Teen STOP-Bang and systemic history · Yes / No / Not sure
Teen STOP-Bang validated risk factors YesNoNot sure
Is the adolescent male, or assigned male at birth? Male sex is a validated risk factor in both the standard and teen STOP-Bang instruments.
Is the adolescent's BMI above the 95th percentile for their age? BMI above the 95th percentile for age is a specific criterion in the validated teen STOP-Bang instrument.
Has a provider noted elevated blood pressure at or above the 95th percentile for the adolescent's age and height?
Has a provider noted a neck circumference above the 95th percentile for age? Larger neck circumference relative to age is associated with increased upper airway soft tissue burden.
Medical, developmental, and environmental history
YesNoNot sure
Has the adolescent been evaluated for or diagnosed with ADHD or any learning difference? ADHD symptoms and adolescent OSA overlap significantly. Airway screening is a valuable complement to any ADHD evaluation.
Has the adolescent been evaluated for or diagnosed with autism spectrum disorder?
Has the adolescent been diagnosed with asthma?
Has the adolescent been diagnosed with or evaluated for any connective tissue condition? Including Ehlers-Danlos syndrome, Marfan syndrome, joint hypermobility syndrome, or similar.
Does the adolescent have unusually flexible or "double-jointed" joints?
Has the adolescent been diagnosed with Down syndrome or any chromosomal condition?
Has the adolescent been diagnosed with prediabetes, insulin resistance, or high cholesterol?
For female adolescents: are menstrual cycles irregular, absent, or accompanied by unusual fatigue? Menstrual irregularity and hormonal disruption have known connections to airway-related conditions including PCOS, which carries elevated OSA risk.
Has the adolescent been diagnosed with PCOS?
Was the adolescent born prematurely or were there significant birth complications?
Is the adolescent regularly exposed to cigarette smoke, vaping, or secondhand smoke?
Does the adolescent smoke or vape themselves?
Is there a family history of snoring, sleep apnea, recessed jaw, crowded teeth, or tonsil and adenoid problems? Craniofacial and airway patterns have a strong hereditary component.
Has the adolescent ever been evaluated by an ENT, sleep specialist, or oral medicine provider?
Overall Concern
Based on the OSA-18 quality-of-life framework · 0 = No concern · 10 = Very concerned
01234 5678910
Caregiver: How concerned are you that the adolescent's breathing or sleep is affecting their health, mood, or development?
0
1
2
3
4
5
6
7
8
9
10
Adolescent self-report: How much does your sleep or breathing affect how you feel, function, or experience daily life?
0
1
2
3
4
5
6
7
8
9
10
For the Clinician
This instrument is part of the AirwayZ Airway Health Inventory, a five-instrument comprehensive screening tool spanning birth through adulthood, developed by Elizabeth Walker, DMD, MSD. This adolescent instrument synthesizes validated content from the Pediatric Sleep Questionnaire (Chervin et al., 2000), the BEARS framework (ages 13–18 scale), the teen STOP-Bang modification (Spruyt and Gozal, 2012; Kadmon et al., 2014), and the OSA-18 quality-of-life instrument, augmented with orofacial myofunctional domains, structural/craniofacial flags, mood and mental health domains, academic and driving safety items, menstrual history, and connective tissue and metabolic history not captured in standard instruments. The dual caregiver/self-report format reflects the clinical reality that adolescent self-report and caregiver observation frequently diverge and that both perspectives carry independent clinical value. Composite scoring is intentionally absent. Discordance between caregiver and self-report columns is itself a clinically meaningful finding. Items in Section 3 warrant careful clinical attention given the well-documented overlap between adolescent OSA and depression, anxiety, and low self-esteem.
A Note for Caregivers and Adolescents
For caregivers
Many symptoms of sleep-disordered breathing in teenagers are easy to attribute to adolescence itself: mood changes, fatigue, poor motivation, weight gain. When these patterns are persistent or affecting functioning, they are worth raising with a provider. This form is a starting point for that conversation.
For adolescents
You know your own experience better than anyone else. The self-report column is yours to fill out honestly, and your answers carry real clinical weight. Fatigue, headaches, jaw pain, low mood: these are not just part of growing up. They are patterns a provider can evaluate and often help with.
What to do next
Share this form with a pediatrician, family physician, dentist or orthodontist with airway training, or a sleep specialist. If your provider is not familiar with airway-focused care, visit airwayz.com to find an affiliated clinician near you.
About mood and mental health findings
Depression, anxiety, and social withdrawal in this form are not character judgments. They are recognized, evidence-based signals of disrupted sleep physiology. When airway-related contributors are identified and addressed, these patterns often improve significantly.
AirwayZ
Elizabeth Walker, DMD, MSD  ·  TreatOrigin Productions, LLC
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