Sleep & Airway Group
Pediatric Sleep Questionnaire

Your Name *

First Name

Last Name

Your Child's Name *

First Name

Last Name

Phone *

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

Yes

No

Don't Know

While sleeping does your child always snore?

Yes

No

Don't Know

While sleeping does your child snore loudly?

Yes

No

Don't Know

While sleeping does your child have “heavy” or loud breathing?

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

Does your child occasionally wet the bed?

Yes

No

Don't Know

Does your child wake up feeling un-refreshed in the morning?

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

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

Yes

No

Don't Know

Does your child wake up with headaches in the morning?

Yes

No

Don't Know

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

Yes

No

Don't Know

Is your child overweight?

Yes

No

Don't Know

Your child often does not seem to listen when spoken to directly

Yes

No

Don't Know

Your child often has difficulty organizing tasks

Yes

No

Don't Know

Your child often is easily distracted by extraneous stimuli

Yes

No

Don't Know

Your child often fidgets with hands or feet or squirms in seat

Yes

No

Don't Know

Your child often is “on the go” or often acts as if “driven by a motor”

Yes

No

Don't Know

Your child often interrupts or intrudes on others (e.g. butts into conversations or games)

Yes

No

Don't Know