• MYOSLEEP KIDS QUESTIONNAIRE

    PATIENT USE ONLY
  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gender*

  • Contact Details

  • Format: 0000 000 000.
  • Format: 0000 000 000.

  • MYOSLEEP KIDS QUESTIONNAIRE

  • How does your child sleep?

  • Sleeping moon

    Answer based on your child's average sleep habits over the past month. If you're unsure about an answer, choose the ? option.

  • 1. Going to sleep

    4 questions
  • Does your child have any problems going to bed or falling asleep?*
  • Does your child tend to have an irregular bedtime?*
  • Does your child tend to have an irregular wake time?*
  • Does your child’s bedtime/wake time differ greatly between weekdays and weekends?*

  • 2. While sleeping

    11 questions
  • Does your child wake up often during the night after falling asleep?*
  • Does your child have their mouth open while sleeping?*
  • Does your child have heavy or loud breathing habits while asleep?*
  • Does your child snore for more than half of the night’s sleep duration?*
  • Does your child snore for more than three or four nights out of the week?*
  • Does your child snore every night?*
  • Does your child snore loudly?*
  • Does your child have difficulty breathing at night while sleeping?*
  • Does your child ever stop breathing while sleeping?*
  • Does your child have regular nightmares, sleep walk or have any other unusual sleep behaviours?*
  • Does your child occasionally wet the bed?*

  • 3. While awake

    14 questions
  • Does your child have a dry mouth when they wake up in the morning?*
  • Does your child find it difficult to wake in the morning?*
  • Does your child wake up feeling unrefreshed in the morning?*
  • Does your child seem overly tired or take excessive naps during the day for their age?*
  • Does your child wake up with headaches in the morning?*
  • Do you think your child is failing to get enough sleep for his/her age?*
  • Has a teacher or other supervisor commented that your child appears unusually sleepy during the day?*
  • Does your child tend to breathe through the mouth while awake?*
  • Is your child’s overall growth slower than the average child for their age?*
  • Is your child overweight?*
  • Does your child have difficulty organising tasks and activities for their age?*
  • Does your child appear to not listen when spoken to directly?*
  • Does your child get easily distracted, fidget or struggle to sit still?*
  • Is your child hyperactive?*

  • REVIEW

  • Almost done

  • Date
     . .
    2 digit day, 2 digit month, 4 digit year

  • I confirm that the information I have provided above is true and accurate to the best of my knowledge. I agree to inform The Myobrace Centre® / The Myosa Centre® of any changes to my medical or dental history. I consent to The Myobrace Centre® / The Myosa Centre® conducting a preliminary dental, orthodontic and/or temporomandibular joint (TMJ) evaluation and understand that this evaluation is not diagnostic and cannot be presented in written form until such a time that diagnostic records have been taken and a second consultation has been attended.

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