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Pediatric Sleep Questionnaire
Please enter the full name of who you are filling this survey out for
While sleeping, does your child snore more than half of the time?
Yes
No
Other
While sleeping, does your child snore loudly?
Yes
No
Sometimes
Other
While sleeping, does your child have “heavy” or loud breathing?
Yes
No
Sometimes
Other
While sleeping, does your child have trouble breathing, or struggle to breathe?
Yes
No
Sometimes
Other
Have you ever seen your child stop breathing during the night?
Yes
No
Sometimes
Other
Does your child occasionally wet the bed?
Yes
No
Sometimes
Other
Does your child occasionally sleep walk?
Yes
No
Sometimes
Other
Does your child have night terrors?
Yes
No
Sometimes
Other
Does your child have dry mouth upon waking in the morning?
Yes
No
Sometimes
Other
Does your child wake up refreshed in the morning?
Yes
No
Sometimes
Other
Does your child wake up with headaches in the morning?
Yes
No
Sometimes
Other
Is it hard for your child to wake up in the morning?
Yes
No
Other
Does your child have any problems with “sleepiness “ during the day?
Yes
No
Other
Has a teacher or supervisor ever commented on the “sleepiness “ or tiredness level of your child?
Yes
No
Other
Did your child stop growing at a normal rate at any point since birth?
If yes, please elaborate in box labeled "other"
Yes
No
Other
Is your child overweight?
Yes
No
Other
Does your child listen when spoken to?
Yes
No
Other
Does your child have difficulty organizing task and activities?
Yes
No
Other
Is your child easily distracted by strenuous stimuli?
Yes
No
Other
Does your child fidget with their hands, feet, or squirms in their seat?
Yes
No
Other
Is your child often, “on the go” or sometimes acts as if “driven by motor”
Yes
No
Other
Does your child often interrupt or intrude?
Yes
No
Other
Please leave your email below if you would like a therapist to contact you
We will not share your email with any third party sources, this is only meant for informational purposes only.
Thank you!