Pediatric Sleep Questionnaire

"*" indicates required fields

Full Name*

Date of Birth

Email*

While sleeping, does your child ever snore?

Yes

No

While sleeping, does your child snore more than half the time?

Yes

No

While sleeping, does your child always snore?

Yes

No

While Sleeping, does your child snore loudly?

Yes

No

While sleeping, does your child have "heavy" or loud breathing?

Yes

No

While sleeping, does your child have trouble breathing or struggle to breathe?

Yes

No

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

Yes

No

Have you ever been concerned about your child's breathing during sleep?

Yes

No

Have you ever had to shake your sleeping child to get him or her to breathe or to wake up and breathe?

Yes

No

Have you ever seen your child wake up with a snorting sound?

Yes

No

Does your child have restless sleep?

Yes

No

At night, does your child usually become sweaty or do the pajamas usually become wet with perspiration?

Yes

No

At night, does your child usually get out of bed to urinate?

Yes

No

Does your child usually sleep with the mouth open?

Yes

No

Is your child's nose usually congested or stuffy at night?

Yes

No

Do any allergies affect your child's ability to breathe through the nose?

Yes

No

Does your child tend to breathe through the mouth during the day?

Yes

No

Does your child have a dry mouth on waking up in the morning?

Yes

No

Does your child complain of an upset stomach at night?

Yes

No

Does your child get a burning feeling in the throat at night?

Yes

No

Does your child grind his or her teeth at night?

Yes

No

Does your child occasionally wet the bed?

Yes

No

UntitledDoes your child wake up feeling unrefreshed in the morning?

Yes

No

Does your child have a problem with sleepiness during the day?

Yes

No

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

Yes

No

Does your child usually take a nap during the day?

Yes

No

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

Yes

No

Does your child wake up with headaches in the morning?

Yes

No

Did your child stop growing at a normal rate at any time since birth?

Yes

No

Is your child overweight?

Yes

No

This child often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Yes

No

This child often has difficulty sustaining attention in tasks or play activities.

Yes

No

This child often does not seem to listen when spoken to directly.

Yes

No

This child often does not follow through on instructions and fails to finish schoolwork, chores or duties.

Yes

No

This child often has difficulty organizing tasks and activities.

Yes

No

This child often avoids, dislikes or is reluctant to engage in tasks or activities that require sustained mental effort (such as homework or schoolwork).

Yes

No

This child often loses things necessary for tasks or activities. (e.g. toys, pencils, books, tools)

Yes

No

This child is often easily distracted by extraneous stimuli.

Yes

No

This child is often forgetful in daily activities.

Yes

No

This child often fidgets with hands or feet or squirms in seat.

Yes

No

This child often leaves seat in classroom or in other situations in which remaining seated is expected.

Yes

No

This child often runs about or climbs excessively in situations where it is inappropriate.

Yes

No

This child often has difficulty playing or engaging in leisure activities quietly.

Yes

No

This child is often "on the go" or often acts as if "driven by a motor".

Yes

No

This child often talks excessively.

Yes

No

Pediatric Sleep Questionnaire

Related Pages

Airway & Sleep Group

Office Hours

Reclaim Your Restless Nights

Contact Us

Airway & Sleep Group

Office Hours