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?
No
Yes
While sleeping does your child have "heavy" or loud breathing?
No
Yes
While sleeping does your child have trouble breathing, or struggle to breathe?
No
Yes
Have you ever seen your child stop breathing during the night?
No
Yes
Does your child occasionally (check all that apply):
Wet the bed?
Sleepwalk?
Have night terrors?
Does your child tend to breathe through the mouth during the day?
No
Yes
Does your child have a dry mouth on waking up in the morning?
No
Yes
Does your child wake up unrefreshed in the morning?
No
Yes
Does your child wake up with a headache in the morning?
No
Yes
Does your child have frequent sore throats or nasal congestion?
No
Yes
Is it hard to wake your child up in the morning?
No
Yes
Does your child have a problem with sleepiness during the day?
No
Yes
Has a teacher commented that your child appears sleepy during the day?
No
Yes
Did your child stop growing at a normal rate at any time since birth?
No
Yes
Is your child overweight?
No
Yes
Are you concerned about your child's sleep?
No
Yes
Child often does not seem to listen when spoken to directly.
No
Yes
Child often has difficulty organizing tasks and activities.
No
Yes
Child often is easily distracted by extraneous stimuli.
No
Yes
Child often fidgets with hands or feet or squirms in seat.
No
Yes
Child often is "on the go" or often acts as if "driven by a motor".
No
Yes
Child often interrupts or intrudes on others (butts into conversations or games).
No
Yes