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Pediatric Sleep Disorder Screening
Patient First Name:
Patient Last Name:
Date Of Birth:
Current Age:
Person Completing this Form:
Relationship to Patient:
Date Form Completed:
WHILE SLEEPING, DOES YOUR CHILD:
Snore more than half the time?
Always Snore?
Snore Loudly?
Have "heavy" or loud breathing?
Have trouble breathing or struggle to breathe?
Ever seem to STOP BREATHING?
DOES YOUR CHILD:
Tend to breathe through the mouth during the day?
Have a dry mouth on waking up?
Have occasional trouble with bed-wetting?
Wake up feeling unrefreshed?
Have a problem with sleepiness during the day?
Wake with headaches in the morning?
HAS A TEACHER OR OTHER SUPERVISOR COMMENTED THAT YOUR CHILD APPEARS SLEEPY DURING THE DAY?
IS IT DIFFICULT TO WAKE YOUR CHILD IN THE MORNING?
DID YOUR CHILD STOP GROWING AT A NORMAL RATE AT ANY TIME SINCE BIRTH?
IS YOUR CHILD OVERWEIGHT?
Weight:
Height:
HAS A TEACHER OR OTHER SUPERVISOR COMMENTED THAT YOUR CHILD APPEARS SLEEPY DURING THE DAY?
MY CHILD OFTEN:
Does not seem to listen when spoken to directly:
Fidgets with hands or feet or squirms in seat:
Has difficulty organizing tasks and activities:
Is always "on the go" or acts as if driven by a motor:
Is easily distracted by extraneous stimuli:
Interrupts or intrudes on others: (butts into conversations or games)
Please list any other sleep observations or concerns not mentioned above:
Signature of Adult Completing Form:
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