Child Sleep Questionnaire
While Sleeping Does Your Child...
Snore more than half the time?
*
Yes
No
I Don't Know
Always snore?
*
Yes
No
I Don't Know
Snore loudly?
*
Yes
No
I Don't Know
Have ‘heavy’ or loud breathing?
*
Yes
No
I Don't Know
Have trouble breathing or struggle to breathe?
*
Yes
No
I Don't Know
Have you ever seen your child stop breathing while sleeping?
*
Yes
No
I Don't Know
Does Your Child...
Tend to breathe through the mouth during the day?
*
Yes
No
I Don't Know
Have a dry mouth on waking up in the morning?
*
Yes
No
I Don't Know
Occasionally wet the bed?
*
Yes
No
I Don't Know
Wake up feeling un-refreshed in the morning?
*
Yes
No
I Don't Know
Have problems with sleepiness during the day?
*
Yes
No
I Don't Know
Has a teacher or other supervisor commented that your child appears sleepy during the day?
*
Yes
No
I Don't Know
Is it hard to wake up your child in the morning?
*
Yes
No
I Don't Know
Does your child wake up with headaches in the morning?
*
Yes
No
I Don't Know
Did your child stop growing at a normal rate at any time since birth?
*
Yes
No
I Don't Know
Is your child overweight?
*
Yes
No
I Don't Know
This Child Often...
Does not seem to listen when spoken to directly
*
Yes
No
I Don't Know
Has difficulty organizing tasks
*
Yes
No
I Don't Know
Is easily distracted by extraneous stimuli
*
Yes
No
I Don't Know
Fidgets with hands or feet or squirms in seat
*
Yes
No
I Don't Know
Is “on the go” or often acts as if “driven by a motor”
*
Yes
No
I Don't Know
Interrupts or intrudes on others (E.g. butts into conversations or games)
*
Yes
No
I Don't Know
Total Number of YES Responses:
If eight or more statements are answered “yes”, consider referring for sleep evaluation.
Name
First Name
Last Name
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Submit
Should be Empty: