Pediatric Sleep Questionnaire

Date:

Patient's Name: Date of Birth:

Age Height: Weight: Sex: M F

Questionnaire filled by: Relation to Patient

Your Phone Number :

Name of Referring Physician(s):

Name: Phone:

Name: Phone:

Any Current Medical Problem?

1- 2-

3- 4-

Past Medical History:

1- 2-

Previous Surgery(s):

Allergy to medicine :

Seasonal Allergy

Any history of weight change?

Gain Loss

How much? Over How Long?

Reason for referral:

At what age was this started:

A) Prepration For Sleep:

What is the usual supper time ?

What Does Your child do from supper time till he/she to bed?

Where does he/she fall asleep usually? ( His/Her bed, Sofa, parents bed ,etc.)

B) Sleep History :

How long will it take to fall asleep?

Usual bedtime:

Weekday Weekend

Usual wake up time:

Weekday Weekend

Is it hard to wake him/her up in the morning?

Weekday Weekend

Does he/she feel sleepy or tired in the morning?

Weekday Weekend

Usual hours of sleep:

Weekday Weekend

Does he/she wake up at night? Yes No

If yes, how often: Reason:

During sleep, does this patient:

Snore? Loudly? Snore throughout the night?

How long? Disturbing to others?

Gasp for air? Sleep with mouth open?

Stop breathing? Have restless sleep?

Look pale or blue? Sound congested or stuffed?

Become sweaty? Mouth breather?

Make a snorting sound and wake him/herself from sleep?

Any abnormal movement during sleep?

Have “growing pains” (unexplained leg pain)?

Have “growing pains” that are worse at night?

Kick with his/her legs briefly while asleep?

Grind his/her teeth at night? Yes No

C) Daytime Behavior and other Possible Problems:

Breathe through mouth Wake up with headache in a.m.

Take a nap: How long? When?

Hyperactivity/Inattention:

Difficulty sustaining attention, starts something new before finishing task

Rarely Sometimes Often Always

Does not seem to follow through with instructions and fails to finish school work or other duties, chores, etc.

Rarely Sometimes Often Always

Runs about or climbs excessively in situations where it is inappropriate.

Rarely Sometimes Often Always

Teacher Observation

Hyperactivity?

Short attention span?

Napping?

Falling grades?

D) Excessive Daytime Sleepiness:

Has he/she felt an irresistible urge to take a nap at an odd time, forcing him/her to stop what he/she is doing in order to sleep?

If so, at what age did this develop?

Does your child have any sleepiness during the day?

If yes, what time of the day?

Has he/she ever found themselves awake in bed able to look around, but unable to move for a short period?

Has he/she ever become suddenly weak in the legs or anywhere else after laughing, being angry, or being surprised by something?

Has he/she ever sensed that he/she was dreaming (seeing images or hearing sounds) while still awake?

Others:

Does he/she drink caffeinated beverages (coffee, tea, cola) on a typical day?

How many cups or cans per day? When?

Any smoking? Drug abuse? Alcohol abuse?

E) Bed Wetting:

(Answer these questions ONLY if your child is bed wetting and over 5 years of age.)

Frequent Urination Yes No

Pain in urination Yes No

History of bladder infection Yes No

Allergy Yes No

Seizure Yes No

Bed wetting since birth Yes No

If no, what age restarted

Bed wetting during the day Yes No

Bed wetting during the night Yes No

Back problems (spina bifida) Yes No

Family history of bed wetting Yes No

Any history of sleep problems : Sleep Walking Nightmares Sleep Terrors Snoring

F) Depression/Insomnia:

Difficulty initiating sleep Yes No

Waking up frequently from sleep? Yes No

Waking up early in the AM? Yes No

Feeling fatigue during the day? Yes No

Inability to concentrate or remember things? Rarely Sometimes Often Always

Decreased or loss of appetite? Rarely Sometimes Often Always

Feels depressed, sad, or irritable? Rarely Sometimes Often Always

Feelings of guilt, hopelessness? Rarely Sometimes Often Always

G) Other Comments: