Sleep Questionnaire

* First Name:
* Last Name:
* Date of Birth:
* Person Completing Form:
While sleeping does the patient...

Snore more than half of the time?

Always snore?

Snore loudly?

Have heavy or loud breathing?

Have trouble breathing?

Has the patient ever...

Stopped breathing during the night?

Does the patient...

Tend to breathe through the mouth during the day?

Have a dry mouth on 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 anyone ever commented that this patient appears sleepy during the day?

Does this patient have difficulty waking up in the morning?

Wake up with headaches in the morning?

Has the patient ever stopped growing at a normal rate at any time since birth?

Is this patient overweight?

This patient often has difficulty...

Listening when spoken to directly

Has difficulty organizing tasks/Is easily distracted by extraneous stimuli

Fidgeting with hands and feet or squirms in 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)

If eight or more statements are answered Yes, consider referring for sleep evaluation.