Pediatric Sleep Questionnaire

(screening for Snoring, Sleeping, and Behavioral Problems

Patient Name:

Date Of Birth:

Date:

 
While sleeping, does your child...
Have trouble breathing or struggle to breath?YesNoDon't No
Stop breating during the night?YesNoDon't No
Have "heavy" or loud breathing?YesNoDon't No
Snore regularly?YesNoDon't No
Snore more than half the time?YesNoDon't No
Appear to be a restless sleeper?YesNoDon't No
Child kick during sleep?YesNoDon't No
Have nightmares?YesNoDon't No
Scream in their sleep?YesNoDon't No
Grind their teeth during sleep?YesNoDon't No
Sleepwalk?YesNoDon't No
Occasionally wet the bed?YesNoDon't No
 
Upon awakening, does your child...
Have a dry mouth in the morning?YesNoDon't No
Tend to breathe through the mouth during the day?YesNoDon't No
Wake up feeling un-refreshed in the morning?YesNoDon't No
Have a problem with sleepiness during the day?YesNoDon't No
Have trouble getting going in the morning?YesNoDon't No
Wake up with headaches in the morning?YesNoDon't No
 
We have noticed that our child...
Does not seem to listen when spoken to directlyYesNoDon't No
Has difficulty organizing tasksYesNoDon't No
Is easily distracted by extraneous stimuliYesNoDon't No
Fidgets with hands or feet or squirms in seatYesNoDon't No
Interrupts or intrudes on others (e.g. butts into conversations or games)YesNoDon't No
Has a teacher or other supervisor comment that your child appears sleepy during the dayYesNoDon't No
Has been diagnosed with ADD or ADHDYesNoDon't No
 
Additionally...
Did your child stop growing at a normal rate at any time since birth?YesNoDon't No
Is your child overweight?YesNoDon't No
Does your child's teeth seem crooked or misaligned?YesNoDon't No
Does your child have allergies?YesNoDon't No
Does your child have frequent colds?YesNoDon't No
Does your child have difficulty with pronunciation?YesNoDon't No
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