Form

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: