PEDIATRIC SLEEP QUESTIONNAIRE
(PATIENTS UNDER 18 YEARS OF AGE)
First Name:
Middle Initial:
Last Name:
Age:
Date:
Please answer on behalf of your child for the past month.
If you don't know select "?"
While sleeping, does your child . . .
1. snore more than half the time?
Yes
No
?
2. always snore?
Yes
No
?
3. snore loudly?
Yes
No
?
4. have trouble breathing, or struggle to breathe?
Yes
No
?
5. have “heavy” or loud breathing?
Yes
No
?
6. have you ever seen your child stop breathing during the night?
Yes
No
?
Does your child . . .
7. tend to breathe through the mouth during the day?
Yes
No
?
8. have a dry mouth on waking up in the morning?
Yes
No
?
9. occasionally wet the bed?
Yes
No
?
10. wake up feeling unrefreshed in the morning?
Yes
No
?
11. have a problem with sleepiness during the day?
Yes
No
?
12. has a teacher commented that your child appears sleepy during the day?
Yes
No
?
13. is it hard to wake your child up in the morning?
Yes
No
?
14. does your child wake up with headaches in the morning?
Yes
No
?
15. did your child stop growing at a normal rate at any time since birth?
Yes
No
?
16. is your child overweight?
Yes
No
?
My child often . . .
17. does not seem to listen when spoken to directly.
Yes
No
?
18. has difficulty organizing task and activities
Yes
No
?
19. is easily distracted by extraneous stimuli.
Yes
No
?
20. fidgets with hands or feet or squirms in seat.
Yes
No
?
21. is ‘on the go’ or often acts as if ‘driven by a motor’
Yes
No
?
22. interrupts or intrudes on others (e.g. butts into conversations or games)
Yes
No
?