• Pediatric Sleep Questionnaire

    Use this form to assess pediatric sleep issues. Complete all required questions and enter the patient and guardian details before submitting.

  • Patient Information

  • Patient Birthdate*
     - -

  • Sleep and Breathing Symptoms

  • While sleeping, does your child...

  • 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 seen your child stop breathing during the night?*

  • Does your child...

  • Tend to breathe through their mouth during the day?*
  • Have a dry mouth on waking up in the morning?*
  • Occasionally wet the bed?*
  • Wake up feeling un-refreshed in the morning?*
  • Have problems with sleepiness during the day?*
  • Has a teacher or other supervisor who has commented that your child appears sleepy during the day?*
  • Is it difficult to wake your child up in the morning?*
  • Wake up with headaches in the morning?*
  • Did your child stop growing at a normal rate at any time since birth?*
  • Is your child overweight?*

  • Behavioral Symptoms

  • My child often...

  • Does not seem to listen when spoken to directly*
  • Has difficulty organizing tasks 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 a motor*
  • Interrupts or intrudes on others (e.g., butts into conversations or games)*

  • More than 8 positive responses may indicate a problem with sleep related breathing disorder
     

  • Should be Empty: