Pediatric Sleep Questionnaire

Name: Gorton & Schmohl Orthodontics
Brand: Gorton & Schmohl Orthodontics
Rating: 4.7 (35 reviews)

Instructions: Please answer the questions about your child IN THE PAST MONTH.

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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