Pediatric Sleep Questionnaire

* First Name:
MI:
* Last Name:
* Date of Birth:
Submission Date:
While sleeping does your child?

Snore more than half of 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 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 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 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 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)

This questionnaire is to evaluate for suspected sleep disordered breathing in your child. If 8 or more yes answers are marked a referral for a sleep evaluation is strongly indicated. Please feel free to ask any questions prior to or during completion if they should arise.