Name of the child

Date of birth

Name of person completing the form

Email

Date that you are completing the questionnaire:

1.1 While sleeping, does your child: Snore more than half the time?

Yes
No
Don't know

1.2 While sleeping, does your child: Always snore?

Yes
No
Don't know

1.3 While sleeping, does your child: Snore loudly?

Yes
No
Don't know

1.4 While sleeping, does your child: Have “heavy” or loud breathing?

Yes
No
Don't know

1.5 While sleeping, does your child: Have trouble breathing, or struggle to breath?

Yes
No
Don't know

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

Yes
No
Don't know

3.1 Does your child: Tend to breathe through the mouth during the day?

Yes
No
Don't know

3.2 Does your child: Have a dry mouth on waking up in the morning?

Yes
No
Don't know

3.3 Does your child: Occasionally wet the bed?

Yes
No
Don't know

4.1 Does your child: Wake up feeling unrefreshed in the morning?

Yes
No
Don't know

4.2 Does your child: Have a problem with sleepiness during the day?

Yes
No
Don't know

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

Yes
No
Don't know

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

Yes
No
Don't know

7. Does your child wake up with headaches in the morning?

Yes
No
Don't know

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

Yes
No
Don't know

9. Is your child overweight?

Yes
No
Don't know

10.1 Does your child often seem not to listen when spoken to directly?

Yes
No
Don't know

10.2 Does your child often have difficulty organizing tasks and activities?

Yes
No
Don't know

10.3 Does your child often fidget with his/her hands or feet, or squirm in his/her seat?

Yes
No
Don't know

10.4 Does your child often seem “on the go” or often act as if “driven by a motor?"

Yes
No
Don't know

10.5 Does your child often interrupt or intrude on others (e.g. butting into conversations or games)?

Yes
No
Don't know

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Pediatric Sleep Questionnaire

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