Pediatric Sleep Questionnaire

MM slash DD slash YYYY
While sleeping, does your child ever snore?
While sleeping, does your child snore more than half the time?
While sleeping, does your child always snore?
While Sleeping, does your child snore loudly?
While sleeping, does your child have "heavy" or loud breathing?
While sleeping, does your child have trouble breathing or struggle to breathe?
Have you ever seen your child stop breathing during the night?
Have you ever been concerned about your child's breathing during sleep?
Have you ever had to shake your sleeping child to get him or her to breathe or to wake up and breathe?
Have you ever seen your child wake up with a snorting sound?
Does your child have restless sleep?
At night, does your child usually become sweaty or do the pajamas usually become wet with perspiration?
At night, does your child usually get out of bed to urinate?
Does your child usually sleep with the mouth open?
Is your child's nose usually congested or stuffy at night?
Do any allergies affect your child's ability to breathe through the nose?
Does your child tend to breathe through the mouth during the day?
Does your child have a dry mouth on waking up in the morning?
Does your child complain of an upset stomach at night?
Does your child get a burning feeling in the throat at night?
Does your child grind his or her teeth at night?
Does your child occasionally wet the bed?
UntitledDoes your child wake up feeling unrefreshed in the morning?
Does your child have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Does your child usually take a nap 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 fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
This child often has difficulty sustaining attention in tasks or play activities.
This child often does not seem to listen when spoken to directly.
This child often does not follow through on instructions and fails to finish schoolwork, chores or duties.
This child often has difficulty organizing tasks and activities.
This child often avoids, dislikes or is reluctant to engage in tasks or activities that require sustained mental effort (such as homework or schoolwork).
This child often loses things necessary for tasks or activities. (e.g. toys, pencils, books, tools)
This child is often easily distracted by extraneous stimuli.
This child is often forgetful in daily activities.
This child often fidgets with hands or feet or squirms in seat.
This child often leaves seat in classroom or in other situations in which remaining seated is expected.
This child often runs about or climbs excessively in situations where it is inappropriate.
This child often has difficulty playing or engaging in leisure activities quietly.
This child is often "on the go" or often acts as if "driven by a motor".
This child often talks excessively.
This field is for validation purposes and should be left unchanged.

Airway & Sleep Group

11800 Sunrise Valley Dr.
Suite 200
Reston, VA 20191

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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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