• Pediatric Sleep Questionnaire

  • Please answer the questions regarding the behavior of your child during sleep and wakefulness. The questions apply to how your child acts in general, not necessarily during the past few days since these may not have been typical if your child has not been well. If you are not sure how to answer any question, please feel free to ask your husband or wife, child, or physician for help.

    When you see the word “usually” it means “more than half the time” or “on more than half the nights.”

  • GENERAL INFORMATION ABOUT YOUR CHILD:

  • Today’s Date:*
     - -
  • Date of Child’s Birth*
     - -
  • Sex:
  • Racial/Ethnic Background of your Child *

  • A. NIGHTTIME AND SLEEP BEHAVIOR:

  • WHILE SLEEPING, DOES YOUR CHILD...

  • ...ever snore?
  • ...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?
  • ...been concerned about your child’s breathing during sleep?
  • ...had to shake your sleeping child to get them to breathe, or wake up and Breathe?
  • ...seen your child wake up with a snorting sound?seen your child wake up with a snorting sound?

  • DOES YOUR CHILD …

  • ...have restless sleep?*
  • ...describe restlessness of the legs when in bed?
  • ...have “growing pains” (unexplained leg pains)?

  • WHILE YOUR CHILD SLEEPS, HAVE YOU SEEN…

  • … brief kicks of one leg or both legs?
  • … repeated kicks or jerks of the legs at regular intervals (i.e., about every 20 to 40 seconds)?

  • AT NIGHT, DOES YOUR CHILD USUALLY…

  • … become sweaty, or do the pajamas usually become wet with perspiration?
  • … get out of bed (for any reason)?
  • … does your child usually sleep with their mouth open?
  • … have a congested or stuffy nose at night?

  • DOES YOUR CHILD …

  • … tend to breathe through the mouth during the day?
  • … have a dry mouth on waking up in the morning?
  • … complain of an upset stomach at night?
  • … get a burning feeling in the throat at night?
  • … grind their teeth at night?
  • … occasionally wet the bed?
  • Has your child ever walked during sleep (“sleepwalking”)?
  • Have you ever heard your child talk during sleep (“sleep talking”)?
  • Does your child have nightmares once a week or more on average?
  • Has your child ever woken up screaming during the night?
  • Has your child ever been moving or behaving, at night, in a way that made you think your child was neither completely awake nor asleep?
  • Does your child have difficulty falling asleep at night?
  • At bedtime does your child usually have difficult “routines” or “rituals,” argue a lot, or otherwise behave badly?

  • DOES YOUR CHILD …

  • … bang his or her head or rock his or her body when going to sleep?
  • … have trouble falling back asleep if he/she wakes up at night?
  • … wake up early in the morning and have difficulty falling back asleep?
  • Does the time at which your child goes to bed change a lot from day to day?
  • Does the time at which your child gets up from bed change a lot from day to day?

  • WHAT TIME DOES YOUR CHILD USUALLY…

  • B. DAYTIME BEHAVIOR AND OTHER POSSIBLE PROBLEMS:

  • DOES YOUR CHILD …

  • … wake up feeling unrefreshed in the morning?
  • … 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?
  • Does your child get a headache at least once a month, on average?
  • Did your child stop growing at a normal rate at any time since birth?*
  • Does your child still have tonsils and or adenoids?*

  • HAS YOUR CHILD EVER…

  • … had a condition causing difficulty with breathing? If so, please describe:*
  • … had surgery?*
  • … become suddenly weak in the legs, or anywhere else, after laughing or being surprised?*
  • … felt unable to move for a short period of time, in bed, though awake and able to look around?*
  • Has your child felt an irresistible urge to take a nap at times, forcing him or her to stop what he or she is doing in order to sleep?*
  • Has your child ever sensed that he or she was dreaming (seeing images or hearing sounds) while still awake?*
  • Does your child drink caffeinated beverages on a typical day (cola, tea,coffee)?*
  • Does your child use any recreational drugs?*
  • Does your child use cigarettes, smokeless tobacco, snuff, or other tobacco products? If so, which ones and how often?:*
  • Is your child overweight?*
  • Has a doctor ever told you that your child has a high-arched palate (roof of the mouth)?*
  • Has your child ever taken Ritalin (Methylphenidate) for behavioral problems? Or been diagnosed with ADD or ADHD?*

  • C. OTHER INFORMATION

  • Rows
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  • D. ADDITIONAL COMMENTS:

    Please use the space below to print any additional comments you feel are important. Please also use this space to describe details regarding any of the above questions. Instructions: Please indicate, by checking the appropriate box, how much each statement applies to this child:
  • … does not seem to listen when spoken to directly.
  • … has difficulty organizing tasks and activities.
  • … is easily distracted by extraneous stimuli.
  • … fidgets with hands or feet or squirms in seat
  • … is “on the go” or often acts as if “driven by a motor”.
  • … interrupts or intrudes on others (e.g., butts into conversations or games
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  • Should be Empty: