Chervin PSQ

This is a validated sleep questionnaire for children two to eighteen years of age.

Answer as best you can for what you have noticed in the last month.

If you don't know the answer or think the question inappropriate for your child then choose "don't know".

Child's name (optional)

First NameLast Name

While sleeping, does your child ...

	Yes	No	Don't Know
Snore more than half the time?
Always snore?
Snore loudly?
Have trouble breathing, or struggle to breathe?
Have "heavy" or loud breathing?
Have you ever seen your child stop breathing during the night?

Does your child ...

	Yes	No	Don't Know
Tend to breathe through the mouth during the day?
Have a dry mouth on waking in the morning?
Occasionally wet the bed?
Wake up feeling unrefreshed in the morning?
Have a problem with sleepiness during the day?
Has a teacher commented that your child appears sleepy during the day?
Is it hard to wake your child in the morning?
Does your child wake up in the morning with headaches?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?

My child often ...

	Yes	No	Don't Know
Does not seem to listen when spoken to directly
Has difficulty organising tasks and activities
Is easily distracted
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)

This Chervin Paediatric Sleep Questionnaire has a sensitivity and specificity for obstructive sleep apnoea in children (2-18 years) of >80%.

Your responses suggest your child may have sleep disordered breathing. Talk to your health professional.

Your responses suggest it is unlikely your child has sleep disordered breathing. If you are still concerned talk to your health professional.

YES

TOTAL

RATIO

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