Pediatric Sleep Quiz

I. Breathing interruptions while sleeping

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

Yes

No

II. Does your child...

1. Always Snore?

Yes

No

2. Snore more than half the time?

Yes

No

3. Snore Loudly?

Yes

No

4. Have "heavy" or loud breathing?

Yes

No

5. Have trouble breathing or struggle to breathe?

Yes

No

6. Tend to breathe through their mouth during the day?

Yes

No

7. Have a dry mouth on waking in the morning?

Yes

No

8. Occasionally wet the bed?

Yes

No

9. Wake up feeling unrefreshed in the morning?

Yes

No

10. Have a problem with sleepiness during the day?

Yes

No

11. Have a teacher or other supervisor who commented that your child sleeps during the day?

Yes

No

12. Find it hard to wake up in the morning?

Yes

No

13. Wake up with headaches in the morning?

Yes

No

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

Yes

No

IV. Is your child overweight?

Yes

No

V. My child often...

1. Does not seem to listen when spoken to directly.

Yes

No

2. Has difficulty organizing tasks and activities.

Yes

No

3. Is easily distracted by extraneous stimuli.

Yes

No

4. Fidgets with hands or feet or squirms in seat.

Yes

No

5. Is 'on the go' or often acts as if 'driven by a motor.'

Yes

No

6. Interrupts or intrudes on others (e.g. butts into conversations or games).

Yes

No

IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOUR CHILD MAY BE AT RISK OF SLEEP APNEA.

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

First Name

Last Name

Phone

Email