Child Sleep Questionnaire

Child Sleep Questionnaire

This form helps to screen for any sleep and breathing disorders in children such as childhood sleep apnea. If you wish to be seen by Dr. Liu to see your child in person at the clinic, please click submit and someone will reach out to you to book an appointment.
Type a question

First NameLast Name
Date of Birth of Child

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Please check any of the following that applies to your child. If you answered YES to 3 or more of these, your child may be at risk for sleep disordered breathing.

While sleeping, your child snores more than half the timeWhile sleeping, your child always snoresWhile sleeping, your child snores loudlyWhile sleeping, your child has heavy or loud breathingWhie sleeping, your child has trouble breathing or struggles to breathYou have seen your child stop breathing during the nightYour child tends to breath through their mouth during the day timeYour child has a dry mouth waking up in the morningYour child wakes up feeling unrefreshed in the morningsYour child has a problem with sleepiness during the daytimeIt is hard to wake up your child in the morningsA teacher or supervisor has commented that your child appears sleepy during the dayYour child wakes up with headaches in the morningYour child stopped growing at a normal rate at some point since birthYour child is overweightYour child often has difficulty organizing tasks and activitiesYour child often does not seem to listen to when spoken to directlyYour child often has trouble focusing in school that it has become concerningYour child very hyperactive that it has become concerningYour child in unable to focus at home that it has become concerningYour family doctor or dentist has noticed your child have large tonsilsYour child has a moderate or severe tongue tieYour child is often congested and has trouble breathing out of their nose
Any other comments or observations?
If you wish to see Dr. Liu at the clinic, please click submit and someone will reach out to you to book an appointment in person. Thank you in advance!
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