Pediatric Sleep Questionnaire
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Please enter the full name of who you are filling this survey out for
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While sleeping, does your child snore more than half of the time?
Yes
No
Other
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While sleeping, does your child snore loudly?
Yes
No
Sometimes
Other
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While sleeping, does your child have “heavy” or loud breathing?
Yes
No
Sometimes
Other
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While sleeping, does your child have trouble breathing, or struggle to breathe?
Yes
No
Sometimes
Other
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Have you ever seen your child stop breathing during the night?
Yes
No
Sometimes
Other
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Does your child occasionally wet the bed?
Yes
No
Sometimes
Other
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Does your child occasionally sleep walk?
Yes
No
Sometimes
Other
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Does your child have night terrors?
Yes
No
Sometimes
Other
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Does your child have dry mouth upon waking in the morning?
Yes
No
Sometimes
Other
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Does your child wake up refreshed in the morning?
Yes
No
Sometimes
Other
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Does your child wake up with headaches in the morning?
Yes
No
Sometimes
Other
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Is it hard for your child to wake up in the morning?
Yes
No
Other
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Does your child have any problems with “sleepiness “ during the day?
Yes
No
Other
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Has a teacher or supervisor ever commented on the “sleepiness “ or tiredness level of your child?
Yes
No
Other
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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
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Is your child overweight?
Yes
No
Other
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Does your child listen when spoken to?
Yes
No
Other
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Does your child have difficulty organizing task and activities?
Yes
No
Other
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Is your child easily distracted by strenuous stimuli?
Yes
No
Other
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Does your child fidget with their hands, feet, or squirms in their seat?
Yes
No
Other
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Is your child often, “on the go” or sometimes acts as if “driven by motor”
Yes
No
Other
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Does your child often interrupt or intrude?
Yes
No
Other
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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!