Form

Pediatric Sleep Questionnaire

Please answer the questions about your child in the past month. Answer the questions with "yes", " no'' or "not sure."

Child's name

Name of person completeing this form

Child's Date Of Birth

While sleeping, does your child snore more then half the time?

While sleeping, does your child always snore?

While sleeping, does your child have "heavy" or loud breathing?

While sleeping, does your child snore loudly?

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

While sleeping, does your child have trouble breathing or struggle to breath?

Does your child tend to breathe through the mouth during the day?

Does your child have a dry mouth on waking up in the morning?

Does your child occasionally wet the bed?

Does your child have a problem with sleepiness during the day?

Has a teacher or other supervisor commented that your child appears sleepy during the day?

Does your child wake up feeling refreshed in the morning?

Is it hard to wake your child up in the morning?

Does your child wake up with headaches in the morning?

Did your child stop growing at a normal rate anytime since birth?

Is your child over weight?

Does your child not seem to listen when spoken to directly?

Does your child have difficulty organizing tasks and activities?

Is your child easily distracted by extraneous stimuli?

Does your child fidget with hands or feet, or squirms in seat?

Is your child "on the go" or often acts as if "driven by a motor"

Does your child interrupt or intrude on others? (eg butts into a conversation or games)

Any Additional Information

Date form was completed

Hoyle Family Dentistry

Dr. Stephen D. Hoyle DDS

(828)692-5786

fax: (828)692-8112

1716 Old Village Road

Hendersonville, NC 28791