Pediatric Sleep Questionnaire
Sleep-Disordered Breathing Subscale
Patient's (Child's) Name:
*
First Name
Last Name
Person Completing Form
*
First Name
Last Name
Relationship to child:
Please Select
Father
Mother
Guardian
Email
*
example@example.com
Phone
Please enter a valid phone number.
Child's Date Of Birth
*
-
Month
-
Day
Year
Please answer "Yes", "No", or "Don't Know" to the following questions. The questions apply to the child's behavior as you've observed it over the past month.
1. WHILE SLEEPING, DOES YOUR CHILD:
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?
2. HAVE YOU EVER SEEN YOUR CHILD:
YES
NO
DON'T KNOW
Stop breathing during sleep?
3. 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?
4. DOES YOUR CHILD:
YES
NO
DON'T KNOW
Wake up feeling unrefreshed in the morning?
Have a problem with sleepiness during the day?
5. HAS A TEACHER OR OTHER SUPERVISOR COMMENTED THAT YOUR CHILD:
YES
NO
DON'T KNOW
Appears sleepy during the day?
6. IS IT DIFFICULT:
YES
NO
DON'T KNOW
To wake your child in the morning?
7. DOES YOUR CHILD:
YES
NO
DON'T KNOW
Wake up with headaches in the morning?
8. DID YOUR CHILD STOP GROWING:
YES
NO
DON'T KNOW
At a normal rate at any time since birth?
9. IS YOUR CHILD:
YES
NO
DON'T KNOW
Overweight?
10. THIS CHILD OFTEN:
YES
NO
DON'T KNOW
Does not seem to listen when spoken to directly
Has difficulty organizing tasks and activities
Is easily distracted by extraneous stimuli
Fidgets with hands or feet/squirms in seat
Is "on the go" or often acts as if "driven by a motor"
Interrupts or intrudes on others (eg., butts into conversations or games)
Risk of Pediatric Sleep-Related Breathing Disorder
The 22 items of the SRBD Scale are each answered "yes" (1), "no" (0), or "don't know" (missing). The number of symptoms-items endorsed positively ("yes") is divided by the number of items answered positively or negatively, the denominator therefore excludes items with missing responses and items answered as "don't know". The result is a number, a proportion that ranges from 0.0 to 1.0. Scores >0.33 are considered positive and suggestive of high risk for a pediatric sleep-related breathing disorder. This threshold is based on a validity study that suggested optimal sensitivity and specificity at the 0.33 cut-off.
Licensed by Facing The Future Orthodontics. ©2006 Regents of the University of Michigan
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