Pediatric Sleep Questionnaire

Patient First Name:
Last Name:

While sleeping does your child...

Snore more than half 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 at 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)?