PEDIATRIC SLEEP QUESTIONNAIRE

PEDIATRIC SLEEP QUESTIONNAIRE
Patient Name*
Date of Birth*

MonthDayYear
Date
Sex

MaleFemale
Age
Parent/Guardian
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Email
example@example.com
Primary Care Provider
Neck size
Height (inches)
Weight
School Grade
Describe your child's main problem(s) in your own words, including when and how this began and what treatment(s) your child has received for this in the past:*
How long has this problem bothered your child?*

The last monthThe last 3 monthsSeveral months1 to 2 yearsLonger than 2 years
How often does this problem occur?*

Every nightAlmost every nightFor periods of at least one weekIrregularlyOther
Is your child being treated for any medical conditions? If so please list below:

Hypertension (high blood pressure)DiabetesLung problems/asthmaADD/ADHDSeizuresStomach or colon problemsRefluxOther
Does your child take any type of medication on a regular basis?*

YesNo
Please list medications, how much, how often and for what reason:
Has his/her tonsils been removed?*

YesNo
When were the tonsils removed?
Has his/her adenoids been removed?*

YesNo
When were the adenoids removed?
Has your child had a weight gain or loss in the last 6 months?*

GainLossNone
How much gained?
How much lost?
Using the scale below, estimate the severity of your child’s problem(s):*

Mildly upsettingModerately upsettingVery severeExtremely severeTotally incapacitating
How would you describe the sleep problem? (Check all that apply)*

Difficulty falling asleepWake up during the nightWake up early in the morningExcessive daytime sleepinessDifficulty awakening
Do any other members of your family have sleep problems?*

YesNo
Please explain:
For your child, rate how often the following occur:
Awaken from sleep short of breath*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Awaken with heartburn, belching or coughing*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Snore*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Snore loudly enough others complain*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have trouble sleeping when he/she has a cold*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Suddenly wakes up gasping for breath during the night*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have breathing problems at night*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Sweat at night*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Experience bedwetting while sleeping*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Fall asleep during the day*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Fall asleep while playing*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Fall asleep when laughing or crying*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Experience weakness when sad or happy*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have trouble at school because of sleepiness*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Feel unable to move (paralyzed) when waking or falling asleep*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Experience dreamlike scenes upon waking up or falling asleep*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Feel afraid of going to sleep*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have nightmares*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Remember his/her dreams*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Feel sad and depressed*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have anxiety (worry about things)*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Notice parts of his/her body jerk*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Kick during the night*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have crawling and aching feeling in his/her legs*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have any type of leg pain during the night*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Have morning jaw pain*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Grind teeth during sleep*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Bothered by pain during the day*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Awakened by pain during the night*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Wake up feeling stiff in the mornings*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Wake up with sore or achy muscles*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Wake up with pain in neck, spine or joints*

Never (No)RarelySometimesFrequentlyConstantly (Yes)
Is your child’s present school situation satisfactory?*

YesNo
Please explain
How many hours of sleep does your child get per night?*
What is your child's typical bedtime on WEEKDAYS?*
What is your child's typical bedtime on WEEKENDS?*
How long does it take for your child to fall asleep (in minutes)?*
Typical number of awakenings per night?*
If he/she awakens, how long does he/she average staying awake (in minutes)?*
Type a question

Type option 1
Type a question

Type option 1
What does your child usually do when he/she awakens during the night?*
When do these awakenings typically happen?*

Soon after falling asleepMiddle of the nightEarly morning
Typical wake up time each WEEKDAY morning?*
Typical wake up time each WEEKEND morning?*
On average, how long does your child stay in bed after waking up in the morning (in minutes)?*
Type a question

Type option 1
Mark all that apply to your child:

Usually sleeps with someone else in his/her bed.Usually sleeps with someone else in his/her room.
Mark all that often disturb your child’s sleep:

HeatColdLightNoiseBed partnerNot being in his/her usual bedOther
Are your child’s sleep habits on the weekends different from the rest of the week?*

YesNo
Please explain
With whom is your child now living? (Siblings, parents, etc., please list ages)*
Does your child drink coffee, tea or soft drinks within two hours of going to bed?*

YesNo
List below the amount of your child’s consumption per day of the following items:
Coffee (in ounces)*
Soft drinks (in ounces)*
Chocolate (in ounces)*
Nicotine (number of times used per day)*
Alcohol (in ounces)*
Over the counter drugs (number of times used per day)*
Other drugs not listed above (number of times used per day)*
Does your child take naps during the afternoon or evening?*

YesNo
How does your child feel after an average night of sleep?*

Usually drowsy and/or tired for up to 1 hourUsually drowsy and/or tired for up to 2 hours.Usually drowsy and/or tired for 3 hours or longer.Good most of the timeConsistently good.
Does your child feel better during the*

MorningAfternoonEvening
Should be Empty:

PEDIATRIC SLEEP QUESTIONNAIRE

For your child, rate how often the following occur:

List below the amount of your child’s consumption per day of the following items: