PEDIATRIC SLEEP QUESTIONNAIRE
Patient Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
Male
Female
Age
Parent/Guardian
Address
Address
Street Address Line 2
City/State/Zip
State / 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 month
The last 3 months
Several months
1 to 2 years
Longer than 2 years
How often does this problem occur?
*
Every night
Almost every night
For periods of at least one week
Irregularly
Other
Is your child being treated for any medical conditions? If so please list below:
Hypertension (high blood pressure)
Diabetes
Lung problems/asthma
ADD/ADHD
Seizures
Stomach or colon problems
Reflux
Other
Does your child take any type of medication on a regular basis?
*
Yes
No
Please list medications, how much, how often and for what reason:
Has his/her tonsils been removed?
*
Yes
No
When were the tonsils removed?
Has his/her adenoids been removed?
*
Yes
No
When were the adenoids removed?
Has your child had a weight gain or loss in the last 6 months?
*
Gain
Loss
None
How much gained?
How much lost?
Using the scale below, estimate the severity of your child’s problem(s):
*
Mildly upsetting
Moderately upsetting
Very severe
Extremely severe
Totally incapacitating
How would you describe the sleep problem? (Check all that apply)
*
Difficulty falling asleep
Wake up during the night
Wake up early in the morning
Excessive daytime sleepiness
Difficulty awakening
Do any other members of your family have sleep problems?
*
Yes
No
Please explain:
For your child, rate how often the following occur:
Awaken from sleep short of breath
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Awaken with heartburn, belching or coughing
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Snore
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Snore loudly enough others complain
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have trouble sleeping when he/she has a cold
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Suddenly wakes up gasping for breath during the night
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have breathing problems at night
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Sweat at night
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Experience bedwetting while sleeping
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Fall asleep during the day
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Fall asleep while playing
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Fall asleep when laughing or crying
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Experience weakness when sad or happy
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have trouble at school because of sleepiness
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Feel unable to move (paralyzed) when waking or falling asleep
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Experience dreamlike scenes upon waking up or falling asleep
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Feel afraid of going to sleep
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have nightmares
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Remember his/her dreams
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Feel sad and depressed
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have anxiety (worry about things)
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Notice parts of his/her body jerk
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Kick during the night
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have crawling and aching feeling in his/her legs
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have any type of leg pain during the night
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Have morning jaw pain
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Grind teeth during sleep
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Bothered by pain during the day
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Awakened by pain during the night
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Wake up feeling stiff in the mornings
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Wake up with sore or achy muscles
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Wake up with pain in neck, spine or joints
*
Never (No)
Rarely
Sometimes
Frequently
Constantly (Yes)
Is your child’s present school situation satisfactory?
*
Yes
No
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 asleep
Middle of the night
Early 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:
Heat
Cold
Light
Noise
Bed partner
Not being in his/her usual bed
Other
Are your child’s sleep habits on the weekends different from the rest of the week?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
How does your child feel after an average night of sleep?
*
Usually drowsy and/or tired for up to 1 hour
Usually drowsy and/or tired for up to 2 hours.
Usually drowsy and/or tired for 3 hours or longer.
Good most of the time
Consistently good.
Does your child feel better during the
*
Morning
Afternoon
Evening
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