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Pediatric Sleep Questionnaire

Name of Child

Date Of Birth

Name of Parent or Gaurdian

Please answer the following questions as they pertain to your child in the past month.

Instructions: Please answer the following questions pertaining your child based on THE PAST MONTH. For this questionnaire, the word "usually" means: "more than half the time" or "on more than half the nights."

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 breath?

Have you ever seen your child stop breathing during the night?

Does your child:

Tend to breath through the mouth during the day?

Have a dry mouth on waking up in the morning?

Occasionally wet the bed?

Wake up feeling unrefreshed in the morning?

Have a problem with sleepiness during the day?

Has a teacher or other supervisor commented that your child appears sleepy during the day?

Is it hard to wake your child up in the morning?

Does your child 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?

This 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 (eg. butts into conversations or games)

Signature of Approval

Parent or Guardian Signature:

Date of Completion