Respiratory Physiology Paediatric OSAS Screening Questionnaire Page 1 11/11 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 : SEX Please 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 “?” CR9035
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Respiratory Physiology Paediatric OSAS Screening
Questionnaire
Page 1
11/11
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
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