Dr. Cruz Pediatric Sleep Questionnaire

Pediatric Sleep Questionnaire
Child’s Name:*

First Name Last Name
Name of Person Answering Questions:*

First Name Last Name
Please answer the questions regarding the behavior of your child during sleep and wakefulness. The questions apply to how your child acts in general, not necessarily during the past few days since these may not have been typical if your child has not been well. If you are not sure how to answer any question, please feel free to ask your husband or wife, child, or physician for help.

When you see the word “usually” it means “more than half the time” or “on more than half the nights.”
GENERAL INFORMATION ABOUT YOUR CHILD:
Today’s Date:*

MonthDay Year
Date
Date of Child’s Birth*

MonthDay Year
Date
Sex:

MaleFemale
Current Height (feet/inches)*
Current Weight (pounds)*
Grade in school (if applicable)
Racial/Ethnic Background of your Child *

AmericanIndianAsian-AmericanWhite/Not HispanicAfrican-AmericanHispanic
A. NIGHTTIME AND SLEEP BEHAVIOR:
WHILE SLEEPING, DOES YOUR CHILD...
...ever snore?

YesNoI don't know
...snore more than half the time?

YesNoI don't know
...always snore?

YesNoI don't know
...snore loudly?

YesNoI don't know
...have heavy or loud breathing?

YesNoI don't know
...have trouble breathing, or struggle to breathe?

YesNoI don't know
HAVE YOU EVER …
...seen your child stop breathing during the night?

YesNoI don't know
If so, please describe what has happened:
...been concerned about your child’s breathing during sleep?

YesNoI don't know
...had to shake your sleeping child to get them to breathe, or wake up and Breathe?

YesNoI don't know
...seen your child wake up with a snorting sound?seen your child wake up with a snorting sound?

YesNoI don't know
DOES YOUR CHILD …
...have restless sleep?*

YesNoI don't know
...describe restlessness of the legs when in bed?

YesNoI don't know
...have “growing pains” (unexplained leg pains)?

YesNoI don't know
...sleep on his/her back, side, stomach or all of the above?
WHILE YOUR CHILD SLEEPS, HAVE YOU SEEN…
… brief kicks of one leg or both legs?

YesNoI don't know
… repeated kicks or jerks of the legs at regular intervals (i.e., about every 20 to 40 seconds)?

YesNoI don't know
AT NIGHT, DOES YOUR CHILD USUALLY…
… become sweaty, or do the pajamas usually become wet with perspiration?

YesNoI don't know
… get out of bed (for any reason)?

YesNoI don't know
If so, how many times?
… does your child usually sleep with their mouth open?

YesNoI don't know
… have a congested or stuffy nose at night?

YesNoI don't know
DOES YOUR CHILD …
… tend to breathe through the mouth during the day?

YesNoI don't know
… have a dry mouth on waking up in the morning?

YesNoI don't know
… complain of an upset stomach at night?

YesNoI don't know
… get a burning feeling in the throat at night?

YesNoI don't know
… grind their teeth at night?

YesNoI don't know
… occasionally wet the bed?

YesNoI don't know
Has your child ever walked during sleep (“sleepwalking”)?

YesNoI don't know
Have you ever heard your child talk during sleep (“sleep talking”)?

YesNoI don't know
Does your child have nightmares once a week or more on average?

YesNoI don't know
Has your child ever woken up screaming during the night?

YesNoI don't know
Has your child ever been moving or behaving, at night, in a way that made you think your child was neither completely awake nor asleep?

YesNoI don't know
If so, please describe what has happened?
Does your child have difficulty falling asleep at night?

YesNoI don't know
How long does it take your child to fall asleep at night? (a guess is O.K.)
At bedtime does your child usually have difficult “routines” or “rituals,” argue a lot, or otherwise behave badly?

YesNoI don't know
DOES YOUR CHILD …
… bang his or her head or rock his or her body when going to sleep?

YesNoI don't know
… have trouble falling back asleep if he/she wakes up at night?

YesNoI don't know
… wake up early in the morning and have difficulty falling back asleep?

YesNoI don't know
Does the time at which your child goes to bed change a lot from day to day?

YesNoI don't know
Does the time at which your child gets up from bed change a lot from day to day?

YesNoI don't know
WHAT TIME DOES YOUR CHILD USUALLY…
… go to bed during the week?
… go to bed on the weekend or vacation?
… get out of bed on weekday mornings?
… get out of bed on weekend or vacation mornings?
B. DAYTIME BEHAVIOR AND OTHER POSSIBLE PROBLEMS:
DOES YOUR CHILD …
… wake up feeling unrefreshed in the morning?

YesNoI don't know
… have a problem with sleepiness during the day?

YesNoI don't know
Has a teacher or other supervisor commented that your child appears sleepy during the day?

YesNoI don't know
Does your child usually take a nap during the day?

YesNoI don't know
Is it hard to wake your child up in the morning?

YesNoI don't know
Does your child wake up with headaches in the morning?

YesNoI don't know
Does your child get a headache at least once a month, on average?

YesNoI don't know
Did your child stop growing at a normal rate at any time since birth?*

YesNoI don't know
If so, please describe what happened:
Does your child still have tonsils and or adenoids?*

YesNoI don't know
If not, when and why were they removed?
HAS YOUR CHILD EVER…
… had a condition causing difficulty with breathing? If so, please describe:*

YesNoI don't know
… had surgery?*

YesNoI don't know
If so, any difficulties with breathing during or after?
… become suddenly weak in the legs, or anywhere else, after laughing or being surprised?*

YesNoI don't know
… felt unable to move for a short period of time, in bed, though awake and able to look around?*

YesNoI don't know
Has your child felt an irresistible urge to take a nap at times, forcing him or her to stop what he or she is doing in order to sleep?*

YesNoI don't know
Has your child ever sensed that he or she was dreaming (seeing images or hearing sounds) while still awake?*

YesNoI don't know
Does your child drink caffeinated beverages on a typical day (cola, tea,coffee)?*

YesNoI don't know
If so, how many cups or cans per day?
Does your child use any recreational drugs?*

YesNoI don't know
If so, which ones and how often?
Does your child use cigarettes, smokeless tobacco, snuff, or other tobacco products? If so, which ones and how often?:*

YesNoI don't know
If so, which ones and how often ?
Is your child overweight?*

YesNoI don't know
If so, at what age did this first develop?
Has a doctor ever told you that your child has a high-arched palate (roof of the mouth)?*

YesNoI don't know
Has your child ever taken Ritalin (Methylphenidate) for behavioral problems? Or been diagnosed with ADD or ADHD?*

YesNoI don't know
C. OTHER INFORMATION
1. What is the problem that brought you here today?
2. If your child has long-term medical problems, please list the three you think are most significant.

3. Please list any medications your child currently takes:

	Medicine	MG per dose	Taken when?	Side Effects?
01
02
03
04
05

4. Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep:

	Medicine	MG per dose	Taken when?	Side Effects?
01
02
03
04
05

5. Please list any sleep disorders diagnosed or suspected by a physician in your child. For each problem, Note the date it started and whether or not it is still present.
6. Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician in your child. For each problem, please list the date it started and whether or not it is still present.

7. Please list any sleep or behavior disorders diagnosed or suspected in your child’s brothers, sisters, or parents:

	Relative	Condition
01
02
03
04
05

D. ADDITIONAL COMMENTS:

Please use the space below to print any additional comments you feel are important. Please also use this space to describe details regarding any of the above questions. Instructions: Please indicate, by checking the appropriate box, how much each statement applies to this child:
… does not seem to listen when spoken to directly.

Does not applyApplies just a littleApplies quite a bitDefinitely applies most of the time
… has difficulty organizing tasks and activities.

Does not applyApplies just a littleApplies quite a bitDefinitely applies most of the time
… is easily distracted by extraneous stimuli.

Does not applyApplies just a littleApplies quite a bitDefinitely applies most of the time
… fidgets with hands or feet or squirms in seat

Does not applyApplies just a littleApplies quite a bitDefinitely applies most of the time
… is “on the go” or often acts as if “driven by a motor”.

Does not applyApplies just a littleApplies quite a bitDefinitely applies most of the time
… interrupts or intrudes on others (e.g., butts into conversations or games

Does not applyApplies just a littleApplies quite a bitDefinitely applies most of the time
Should be Empty:

Pediatric Sleep Questionnaire

GENERAL INFORMATION ABOUT YOUR CHILD:

A. NIGHTTIME AND SLEEP BEHAVIOR:

B. DAYTIME BEHAVIOR AND OTHER POSSIBLE PROBLEMS:

C. OTHER INFORMATION

D. ADDITIONAL COMMENTS: