Pediatric Sleep Questionnaire

Patient First Name:
Patient Last Name:
Please fill this form as accurately and honestly as possible. In our practice we are very interested in our patients' overall health. Orthodontic treatment can be an important part of managing the health problems caused by sleep and breathing disorders.

While sleeping does your child snore?
While sleeping does your child have "heavy" or loud breathing?
While sleeping does your child have trouble breathing, or struggle to breathe?
Have you ever seen your child stop breathing during the night?
Does your child occasionally (check all that apply):

Does your child tend to breathe through the mouth during the day?
Does your child have a dry mouth on waking up in the morning?
Does your child wake up unrefreshed in the morning?
Does your child wake up with a headache in the morning?
Does your child have frequent sore throats or nasal congestion?
Is it hard to wake your child up in the morning?

Does your child have a problem with sleepiness during the day?
Has a teacher commented that your child appears sleepy during the day?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?
Are you concerned about your child's sleep?

Child often does not seem to listen when spoken to directly.
Child often has difficulty organizing tasks and activities.
Child often is easily distracted by extraneous stimuli.
Child often fidgets with hands or feet or squirms in seat.
Child often is "on the go" or often acts as if "driven by a motor".
Child often interrupts or intrudes on others (butts into conversations or games).