Drooling Measures Form

Date: Name of child: Form completed by: Relationship to child: / /

1.

Is your child currently on medication to reduce drooling? (please tick)

No

Yes

If yes, please give name and amount taken during the last eek:

2.

Has your child been well over the past week? (please tick)

No

Yes

If no, please give details of illness:

!ating scale. "lease discuss these with anyone who knows your child well and circle the number which best re#lects the severity and #re$uency o# drooling over the past week% Fre!uency " $ & ( " $ & ( / No drooling # dry %ccasional drooling # not every day Fre!uent drooling ' every day but not all day )onstant drooling # al ays et Dry # never drools +ild # only the lips are et +oderate # et on the lips and the chin *evere # drools to the e,tent the clothes -/or ob.ects get et 0rofuse # clothing, hands and ob.ects become very et

*everity

&.

'n an average day over the past week when your child is at home% (umber o# bib changes per day% (umber o# clothes changes per day% "lease turn over page1 *aliva )ontrol )linic, Royal )hildren2s 3ospital1 $('4$'"(

For the $uestions )*1&+ please draw a circle around the number between 1 and 1, that indicates the e-tent to which each $uestion about drooling has a##ected you over the past week. For e-ample% How much do television advertisements annoy you?

).

Not at all

"

&

"4

3eaps

How o##ensive was the smell o# the saliva? No smell " $ & ( / 5 6 7 8 "4 9ery offensive

..

How much o# a problem has there been with skin rashes on the chin and around mouth? No rash " $ & ( / 5 6 7 8 "4 *evere rash

/.

How #re$uently did your child0s mouth need wiping? Not at all " $ & ( / 5 6 7 8 "4 :ll the time

1.

How embarrassed did your child seem to be about his2her dribbling? Not at all " $ & ( / 5 6 7 8 "4 9ery embarrassed

3.

How much were you worried by other people0s reactions to your child0s dribbling? Not at all " $ & ( / 5 6 7 8 "4 ;,tremely orried

1,. How much do you have to wipe or clean saliva #rom household items eg toys+ #urniture+ computers etc? Not at all " $ & ( / 5 6 7 8 "4 :ll the time

11. How much o# a problem did your child have with coughing or choking on saliva? No problem " $ & ( / 5 6 7 8 "4 3uge problem

12. 4o what e-tent did your child0s drooling a##ect his or her li#e? Not at all " $ & ( / 5 6 7 8 "4 <reatly

*aliva )ontrol )linic, Royal )hildren2s 3ospital1 $('4$'"(

1 . 4o what e-tent did your child0s dribbling a##ect you and your #amily0s li#e? Not at all " $ & ( / 5 6 7 8 "4 <reatly

1&. 4o what e-tent did your child0s dribbling a##ect others outside the immediate #amily? Not at all " $ & ( / 5 6 7 8 "4 <reatly

1).

5as your child on other medication over the past week?

Yes

No

=nsure

IF Y;*, please include names of medication belo :

1..

Has your child had saliva control surgery?

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:69 ;' 4' 7.1)

1/. How worthwhile do you believe your child0s saliva surgery has been? Not at all " $ & ( / 5 6 7 8 "4 ;,tremely

11. How likely would you be to recommend this surgery to other #amilies in the same circumstances? Discourage " $ & ( / 5 6 7 8 "4 3ighly recommend

<omments%

4hank you #or completing this $uestionnaire. *aliva )ontrol )linic, Royal )hildren2s 3ospital1 $('4$'"(

1).

I# your child is on any medication+ has this changed since the operation?

Yes
If yes, please e,plain:

No

*aliva )ontrol )linic, Royal )hildren2s 3ospital1 $('4$'"(