Pediatric Sleep Questionnaire
Patient First Name:
Last Name:
Birthdate:
While sleeping does your child...
Snore more than half the time?
Yes
No
Don't Know
Always snore?
Yes
No
Don't Know
Snore loudly?
Yes
No
Don't Know
Have "heavy" or loud breathing?
Yes
No
Don't Know
Have trouble breathing or struggle to breathe?
Yes
No
Don't Know
Have you ever...
Seen your child stop breathing at night?
Yes
No
Don't Know
Does your child...
Tend to breathe through the mouth during the day?
Yes
No
Don't Know
Have a dry mouth on waking up in the morning?
Yes
No
Don't Know
Occasionally wet the bed?
Yes
No
Don't Know
Wake up feeling un-refreshed in the morning?
Yes
No
Don't Know
Have a problem with sleepiness during the day?
Yes
No
Don't Know
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Yes
No
Don't Know
Is it hard to wake your child up in the morning?
Yes
No
Don't Know
Does your child wake up with headaches in the morning?
Yes
No
Don't Know
Did your child stop growing at a normal rate at any time since birth?
Yes
No
Don't Know
Is your child overweight?
Yes
No
Don't Know
This child often...
Does not seem to listen when spoken to directly
Yes
No
Don't Know
Has difficulty organizing tasks?
Yes
No
Don't Know
Is easily distracted by extraneous stimuli?
Yes
No
Don't Know
Fidgets with hands or feet or squirms in seat
Yes
No
Don't Know
Is "on the go" or often acts as if "driven by a motor"
Yes
No
Don't Know
Interrupts or intrudes on others (e.g. butts into conversations or games)?
Yes
No
Don't Know