Respiratory Physiology Paediatric OSAS Screening

Questionnaire

Page 1

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P A E D I A T R I C

O S A S

S C R E E N I N G

Q U E S T I O N N A I R E

SURNAME:

FIRST NAME:

DOB:

NHI:

SEXPlease ensure patient details are completed here

Caregiver: _____________________________________________________ Date: _________________ (print) Please answer on behalf of your child for the past month. If you don’t know, circle “?”

CR

9035