Pediatric Sleep Questionnaire

Patient First Name:
Patient Middle Initial:
Patient Last Name:
While sleeping does your child….
Snore more than half the time?
Always snore?
Snore loudly?
Have 'heavy' or 'loud' breathing?
Have trouble breathing or struggle to breathe?
Have you ever…
Seen your child stop breathing during the night?
Does your child…
Tend to breathe through the mouth during the day?
Have a dry mouth when waking up in the morning?
Occasionally wet the bed?
Wake up feeling un-refreshed in the morning?
Have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child up in the morning?
Does your child wake up with headaches in the morning?
Did your child stop growing at a normal rate at any time since their birth?
Is your child overweight?
This child often…
Does not seem to listen when spoken to directly?
Has difficulty organizing tasks?
Is easily distracted by extraneous stimuli?
Fidgets with hands or feet or squirms in the seat?
Is “on the go” or often acts as if “driven by a motor”?
Interrupts or intrudes on others (e.g. butts into conversations or games)?