AirwayZ Inventory

Child Screening Questionnaire

AirwayZ Airway Health Inventory — Child (Ages 4–11)
AirwayZ
Instrument 2 · Child · Ages 4–11
AirwayZ
Airway Health Inventory
Child
Ages 4–11 · Caregiver Report
TreatOrigin Productions, LLC
Child's name
Age / Grade
Date
Caregiver
Pediatrician
Dentist
How to complete
For each item, mark the number or response that best reflects your child's experience over the past several months. Answer based on what you observe. This form is designed to be shared with your child's healthcare provider as a starting point for conversation, not as a diagnosis.
Severity scale
0 Not present   1 Mild   2 Mild-moderate   3 Moderate
4 Moderate-pronounced   5 Pronounced

Initial column = today  ·  F/U column = after 3 months of care
Section 1 · Nighttime & Sleep
Snoring frequency · Mark how often each pattern occurs
Never ~1× / week 2–4× / week Most nights Every night
Does your child snore at all?
Does your child have labored, difficult, or loud breathing during sleep?
While sleeping, does your child... · Severity: 0 (not present) through 5 (pronounced)
012 345 F/U
Sleep with the mouth open?
0
1
2
3
4
5
Sweat heavily or seem uncomfortably warm during sleep?
0
1
2
3
4
5
Move excessively, kick, or seem restless throughout the night?
0
1
2
3
4
5
Sleep with neck hyperextended or head tilted noticeably far back? Children sometimes adopt this position unconsciously to open the airway.
0
1
2
3
4
5
Sleep in unusual positions: propped up on pillows, sitting upright, on hands and knees?
0
1
2
3
4
5
Startle awake suddenly, or wake with gasping, snorting, or an abrupt intake of breath? This pattern is distinct from general restlessness and may reflect brief airway disruption.
0
1
2
3
4
5
Wake frequently during the night without an obvious cause?
0
1
2
3
4
5
Grind or clench their teeth during sleep?
0
1
2
3
4
5
Talk during sleep?
0
1
2
3
4
5
Have night terrors or other parasomnias: episodes of screaming, sitting bolt upright, sleepwalking, or appearing awake but unresponsive during the night? Night terrors and parasomnias are associated with sleep fragmentation and are a recognized feature of sleep-disordered breathing in children.
0
1
2
3
4
5
Wet the bed? Nocturnal enuresis is well-documented as a reversible consequence of untreated sleep-disordered breathing in school-age children.
0
1
2
3
4
5
Have a dry mouth upon waking?
0
1
2
3
4
5
Wake with headaches in the morning, before getting out of bed?
0
1
2
3
4
5
Be difficult to wake in the morning, seeming unrefreshed despite adequate sleep?
0
1
2
3
4
5
Have you ever observed your child... YesNoNot sure
Make choking or gasping sounds during sleep? Choking or gasping sounds during sleep are a distinct signal from witnessed breathing pauses and warrant their own evaluation.
Stop breathing, pause breathing for several seconds, or appear to struggle to breathe during sleep?
Have interrupted snoring: snoring that cuts off abruptly before resuming?
If yes to either above, please describe what you observed, how often, and approximately how long it lasted:
Section 2 · Daytime Symptoms
During waking hours, does your child... · Severity: 0–5
012 345 F/U
Breathe through the mouth during the day?
0
1
2
3
4
5
Have chronic nasal congestion or difficulty breathing through the nose?
0
1
2
3
4
5
Have dark circles under the eyes not explained by illness or poor sleep hygiene? Persistent dark circles ("allergic shiners") can indicate chronic nasal obstruction and disturbed sleep architecture.
0
1
2
3
4
5
Seem sleepy, sluggish, or difficult to engage during the day?
0
1
2
3
4
5
Fall asleep easily in cars, watching TV, or in quiet situations during the day?
0
1
2
3
4
5
Feel sleepy or irritable during the day?
0
1
2
3
4
5
Have frequent morning headaches?
0
1
2
3
4
5
Have recurring headaches at least once a month on average, apart from morning waking headaches?
0
1
2
3
4
5
Have frequent ear infections or recurring fluid in the ears?
0
1
2
3
4
5
Have frequent throat infections, tonsil swelling, or recurring colds and upper respiratory infections?
0
1
2
3
4
5
Have allergic symptoms: runny eyes, skin reactions, eczema, chronic sneezing, or year-round nasal symptoms?
0
1
2
3
4
5
Have asthma symptoms or been diagnosed with asthma?
0
1
2
3
4
5
Have difficulty swallowing, frequent gagging, nausea, or vomiting related to eating? In children with adenotonsillar enlargement, swallowing difficulty and nausea during meals are commonly reported.
0
1
2
3
4
5
Have frequent acid reflux, heartburn, or complaints of stomach pain?
0
1
2
3
4
5
YesNoNot sure
Has a teacher, school counselor, or other caregiver commented that your child appears sleepy, inattentive, or seems to be struggling during the day?
Has your child had a failed hearing screen, hearing test concerns, or been evaluated for hearing loss? Chronic fluid in the ears from nasal obstruction and adenoid hypertrophy is a common cause of conductive hearing loss in this age group.
Section 3 · Behavior & Learning
Does your child... · Severity: 0–5  ·  Many of these patterns overlap with ADHD symptoms and can be related to sleep-disordered breathing
012 345 F/U
Not seem to listen when spoken to directly?
0
1
2
3
4
5
Have difficulty focusing or staying on task?
0
1
2
3
4
5
Have difficulty organizing tasks, activities, or belongings?
0
1
2
3
4
5
Be easily distracted by surroundings or background activity?
0
1
2
3
4
5
Fidget with hands or feet, or squirm and have difficulty sitting still?
0
1
2
3
4
5
Seem hyperactive, "on the go," or as if driven by a motor?
0
1
2
3
4
5
Interrupt or intrude on others' conversations or activities?
0
1
2
3
4
5
Have difficulty in school that doesn't seem fully explained by intelligence or effort?
0
1
2
3
4
5
Show mood problems: persistent irritability, anxiety, or emotional responses that seem disproportionate?
0
1
2
3
4
5
YesNoNot sure
Has a teacher or school professional raised concerns about your child's attention, behavior, or learning?
Section 4 · Oral, Jaw & Structural
Does your child... · Severity: 0–5
012 345 F/U
Rest with the mouth open at baseline: lips apart, tongue low, jaw dropped when relaxed and not speaking or eating? This resting oral posture pattern, distinct from sleep or exercise mouth breathing, reflects the default position of the orofacial structures at rest.
0
1
2
3
4
5
Chew with the mouth open, or seem unable to chew comfortably with lips closed?
0
1
2
3
4
5
Avoid hard or chewy foods, preferring soft textures beyond what is typical for their age?
0
1
2
3
4
5
Have speech that is difficult to understand, nasal in quality, hoarse, or congested-sounding?
0
1
2
3
4
5
Have jaw pain, clicking, or popping in the jaw joint?
0
1
2
3
4
5
Clench or grind their teeth during the day?
0
1
2
3
4
5
Have chronic neck pain, tension headaches, or frequent complaints of head and neck discomfort?
0
1
2
3
4
5
Tongue, lip, and oral posture · Yes / No / Not sure
Roof of mouth Bottom Unsure
Where does your child's tongue rest when their mouth is relaxed and closed? Correct resting posture is tongue flat against the roof of the mouth (the palate), with lips together and teeth lightly touching.
YesNoNot sure
Can your child keep their lips together comfortably when relaxed and at rest, without effort? Lip incompetence, the inability to maintain a relaxed lip seal, is associated with habitual mouth breathing and altered oral development.
Has your child received speech therapy?
Has your child been evaluated for or diagnosed with tongue tie (ankyloglossia) or lip tie? Short lingual frenulum has been identified as an independent risk factor for sleep-disordered breathing in school-age children (Guilleminault et al., 2016).
Has a dentist noted a narrow jaw, high palate, crowded teeth, crossbite, or anterior open bite? These structural findings are characteristic of the "mouth-breather facies" pattern associated with long-term oral breathing and restricted nasal airflow.
Have your child's tonsils or adenoids been evaluated or removed?
Has anyone noted that your child has poor posture or a forward head position? Forward head posture is associated with habitual mouth breathing and reduced pharyngeal airway tone.
Have you or others noticed unusual gait patterns: walking pigeon-toed, duck-footed, or with poor balance? Gait and postural abnormalities have been associated with the full-body postural compensation patterns seen in mouth-breathing children.
Does your child seem clumsy, poorly coordinated, or prone to frequent falls? Have they had delayed gross motor milestones or difficulty with activities requiring balance? Poor gross motor coordination and balance difficulties are part of the broader neuromuscular and postural pattern associated with airway dysfunction and disrupted sleep in children.
Caregiver Concern
Overall concern · Based on the OSA-18 quality-of-life framework
012 345 678 910
How concerned are you that your child's breathing or sleep is affecting their health, behavior, or development? 0 = Not at all concerned  ·  5 = Moderately concerned  ·  10 = Very concerned. Your overall sense as a caregiver is clinically meaningful.
0
1
2
3
4
5
6
7
8
9
10
How much has your child's sleep or breathing affected your own sleep, stress, or daily life as a caregiver? 0 = No impact  ·  5 = Moderate impact  ·  10 = Significant impact
0
1
2
3
4
5
6
7
8
9
10
Section 5 · Development & Medical History
Growth & weight · Yes / No / Not sure
YesNoNot sure
Has your child stopped growing at a normal rate at any point, or has a provider flagged their growth as below expected?
Is your child overweight?
If overweight: at approximately what age did this begin?
Medical, developmental, and environmental history · Yes / No / Not sure
YesNoNot sure
Has your child had repeated chest infections, bronchiolitis, or pneumonia that a provider has treated or been concerned about?
Has a provider ever expressed concern about your child's muscle tone, describing them as floppy, low-toned, or hypotonic?
Has your child been evaluated for, or diagnosed with, ADHD or any learning difference? ADHD symptoms and sleep-disordered breathing symptoms overlap significantly. Airway screening is a valuable complement to any ADHD evaluation in this age group.
Has your child been evaluated for or diagnosed with autism spectrum disorder?
Has your child been diagnosed with Down syndrome or any chromosomal condition? OSA prevalence in children with Down syndrome is significantly higher than in the general pediatric population.
Has your child been diagnosed with or evaluated for any connective tissue condition? Including Ehlers-Danlos syndrome, Marfan syndrome, joint hypermobility syndrome, or similar.
Does your child have unusually flexible or "double-jointed" joints in the fingers, wrists, elbows, or knees?
Has your child been diagnosed with prediabetes, insulin resistance, or high cholesterol?
Was your child born prematurely, or were there significant complications during pregnancy or delivery?
Did your child use a pacifier beyond age 2, or sustain a thumb or finger sucking habit? Prolonged oral habits are associated with altered palatal shape, anterior open bite, and downstream oral breathing patterns.
Is your child regularly exposed to cigarette smoke, vaping, or secondhand smoke in the home or car?
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. A positive family history increases the relevance of other findings on this form.
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. It synthesizes validated content from the Healthy Start / Bergersen Sleep Disordered Breathing Questionnaire, the Pediatric Sleep Questionnaire (Chervin et al., 2000), the Child Sleepiness Questionnaire, the OSA-18, the BEARS framework, and the PSQ-SRBD subscale, augmented with orofacial myofunctional domains (tongue posture, lip seal, lingual frenulum, chewing pattern), structural/craniofacial flags, postural and gait observations, connective tissue conditions, ASD, metabolic history, and family and environmental history not captured in standard instruments. Initial and follow-up columns support treatment tracking over time. Composite scoring is intentionally absent. Individual item patterns and clinical judgment should guide next steps. Items with severity 4 or 5, affirmative responses to witnessed breathing pauses or gasping arousals, and any affirmative response to chromosomal, connective tissue, or metabolic conditions are recommended as priority discussion points.
A Note for Caregivers
What this inventory is
A starting point for a clinical conversation, not a diagnosis. Many of the patterns this form captures are well understood and, when identified early, are highly addressable. Bringing this completed form to your child's provider is a meaningful and proactive step.
What to do next
Share this with your child's pediatrician, family physician, or a dentist or orthodontist with airway training. If your provider isn't familiar with airway-focused care, an AirwayZ-affiliated clinician may be a helpful resource. Visit airwayz.com to find a provider near you.
About behavioral patterns
Many symptoms in Section 3 strongly overlap with ADHD. In school-age children, these patterns are often reversible once airway-related contributors have been identified and addressed. If your child has received an ADHD evaluation, airway screening is a valuable complementary step.
About higher severity patterns
Pronounced patterns in any category, especially around nighttime breathing, daytime sleepiness, or oral-structural findings, are worth raising with a provider sooner rather than later. These findings are recognized and, when addressed, often make a meaningful difference in a child's sleep, attention, growth, and quality of life.
AirwayZ
Elizabeth Walker, DMD, MSD  ·  TreatOrigin Productions, LLC
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