Pediatric Sleep Questionnaire

Pediatric Sleep Questionnaire
Child's Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Age
Height
Weight
Date

MonthDayYear
Date
Relationship to Child
Person Completing form

While Sleeping does your child

	Yes	No
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

	Yes	No
seen your child stop breathing during the night?

Does your child

	Yes	No
tend to breathe through the mouth during the day?
have dry mouth on waking up in the morning?
occasionally wet the bed?

Does your child

	Yes	No
wake up feeling unrefreshed in the morning?
have a problem with sleepiness during the day?
occasionally wet the bed?
wake up with headaches in the morning?
Is it hard to wake your child up in the morning?
Is your child overweight?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Did your child stop growing at a normal rate since birth?

This child often

	Yes	No
does not seem to listen when spoken to directly?
has difficulty organizing task and activities?
is easily distracted by extraneous stimuli?
fidgets with hands or feet or squirms in seat?
is on the go or often acts as if driven by motor?
interrupts or intrudes on others (e.g butts into conversations or games?)
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Did your child stop growing at a normal rate since birth?

East Hampton

87 Newtown Lane
East Hampton, NY 11937

(631) 502-4806
Riverhead

235 Osborn Avenue
Riverhead, NY 11901

(631) 705-8956
Should be Empty: