Pediatric Sleep Questionnaire
(Screening for Snoring, Sleepiness, and Behavioral Problems)
Patient Name
*
First Name
Middle Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
While sleeping, does your child...
*
Rows
Yes
No
Don't Know
have trouble breathing or struggle to breath?
stop breathing during the night?
have "heavy" or loud breathing?
snore regularly?
snore more than half the time?
appear to be a restless sleeper?
child kick during sleep?
have nightmares?
scream in their sleep?
grind their teeth during sleep?
sleepwalk?
occasionally wet the bed?
Upon awakening, does your child…
*
Rows
Yes
No
Don't Know
have a dry mouth in the morning?
tend to breathe through the mouth during the day?
wake up feeling un-refreshed in the morning?
have a problem with sleepiness during the day?
have trouble getting going in the morning?
wake up with headaches in the morning?
We have noticed that our child…
*
Rows
Yes
No
Don't Know
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
interrupts or intrudes on others (e.g. butts into conversations or games)
has a teacher or other supervisor comment that your child appears sleepy during the day
has been diagnosed with ADD or ADHD
Additionally…
*
Rows
Yes
No
Don't Know
did your child stop growing at a normal rate at any time since birth?
is your child overweight?
does your child's teeth seem crooked or misaligned?
does your child have allergies?
does your child have frequent colds?
does your child have difficulty with pronunciation?
Total Number of "Yes" Responses
If eight or more statements are answered "yes", consider referring for sleep evaluation
Submit
Should be Empty: