Pediatric Sleep Questionnaire
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 Breathe
___Have you ever seen your child stop breathing during the night?
Does your Child...?
___Tend to Breathe through the Mouth during the day
___Have a Dry mouth on waking up in the morning
___Occasionally wet the bed
___Grind their teeth while sleeping
___Are there bite problems or crowded teeth
___Wake up Unrefreshed in the morning
___Have a problem with sleepiness during the day
___Has a teacher or other individual commented that your child appears sleepy during the day
___Is it hard to wake your child 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, What is their weight___pounds & height___
___Does your child complain of restless/achy legs when asleep or in bed
___Do your child’s arms or legs “twitch” during sleep
___Does your child have frequent Nightmares (more than one per week) that may disturb him/her during the night