Paediatric Sleep Questionnaire

Paediatric Sleep Questionnaire

(Screening for Snoring, Sleepiness, and Behavioral Problems)
Child's Name

TitleFirst NameMiddle NameLast Name
Preferred Name
Birth Date

DayMonthYear
Any interventions you've tried, including duration

When sleeping, does your child...

Rows	Yes	No	Don't Know
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...

Rows	Yes	No	Don't Know
seen or heard your child stop breathing during the night?

Does your child...

Rows	Yes	No	Don't know
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 unrefreshed in the monring?
have a problem with sleepiness during the day?
has a teacher or other supervisor comment that your child appears sleepy during the day?
Is it hard to wake your child up in the norning?
wake up with headaches in the morning?
stop growing at a normal rate at any time since birth?
Is your child overweight?

This child often...

Rows	Yes	No	Don't Know
does not seem to listen when spoken to directly
has difficulty organising tasks
is easily distracted by extraneous stimuli
fidgets with hands or feet or squirms in the 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)

Total Number of "Yes" responses
If eight or more statements are answered "yes", consider referring for sleep evaluation
DateTime
Email address to receive a copy for your records:
example@example.com
Should be Empty: