Pediatric Sleep Questionnaire

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    Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Instructions: Please answer the questions about your child IN THE PAST MONTH. Mark the correct response. For this questionnaire, the word "usually" means "more than half the time" or "on more than half the nights".

  • 1. While Sleeping, does your child:

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

  • 3. Does your child:

  • 4. Does your child:

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

  • 6. Is it hard to wake your child in the morning?

  • 7. Does your child wake up with headaches in the morning?

  • 8. Did your child stop growing at a normal rate any time since birth?

  • 9. Is your child overweight?

  • 10. My child: