General Pediatric Sleep Questionnaire

Tao Dental Care

https://www.dentaltao.com, 877 W Fremont Ave #C2, Sunnyvale, CA 94087, yuan.tao.dmd@gmail.com, (408) 737-2988
General Pediatric Sleep Questionnaire
Patient Name

Last Name First Name Middle Name
Phone Number

Area Code Phone Number
Date

Month Day Year
Date
Does your Child…? (check all that apply)

Tend to breathe through the mouth during the day Have a dry mouth upon waking up in the morning Occasionally wet the bed Grind his/her teeth while sleeping Have any bite problems or crowded teeth Wake up unrefreshed in the morning Have a problem with daytime sleepiness Have a teacher or anyone who has commented about sleepiness during the day Have difficulty waking up in the morning Wake up with headaches Abnormal head postures (Hyperextension, etc.) during sleep Excessive sweating during sleep Have any history of growth problems Have an overweight issue:
Weight is
Height is
Complain of restless or achy legs Have arms and /or legs that twitch during sleep Have nightmares (More than one per week)
While Sleeping, Does your Child: (check all that apply)

Snore more than half the time Always Snore Snore loudly Have heavy or loud breathing Have trouble breathing or struggles to breathe Break or pause in breathes? Gasp, choke or struggle to breathe? Ever stop breathing at night?
Should be Empty:

Tao Dental Care