Pediatric Sleep Quiz

I. While Sleeping, does your child...

1. Snore more than half the time?*

Yes
No

2. Always Snore?*

Yes
No

3. Snore Loudly*

Yes
No

4. Have "heavy" or loud breathing?*

Yes
No

5. Have trouble breathing or struggle to breathe?*

Yes
No

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

Yes
No

II. Does your child...

1. Tend to breathe through their mouth during the day?*

Yes
No

2. Have a dry mouth on waking in the morning?*

Yes
No

3. Occasionally wet the bed?*

Yes
No

4. Wake up feeling unrefreshed in the morning?*

Yes
No

5. Have a problem with sleepiness during the day?*

Yes
No

6. Have a teacher or other supervisor who commented that your child sleeps during the day?*

Yes
No

7. Find it hard to wake up in the morning?*

Yes
No

8. Wake up with headaches in the morning?*

Yes
No

III. Did your child stop growing at a normal rate at any time since birth?*

Yes
No

IV. Is your child overweight?*

Yes
No

Section Break

V. This child often...

1. Does not seem to listen when spoken to directly.*

Yes
No

2. Has difficulty organizing tasks and activities.*

Yes
No

3. Is easily distracted by etraneous stimuli.*

Yes
No

4. Fidgets with hands or feet or squirms in seat.*

Yes
No

5. Is 'on the go' or often acts as if 'driven by a motor.'*

Yes
No

6. Interrupts or intrudes on others (e.g. butts into conversations or games).*

Yes
No

IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOUR CHILD MAY BE AT RISK OF SLEEP APNEA

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

Name*

Name

Phone*

Email*

Message*

Email

This field is for validation purposes and should be left unchanged.

I. While Sleeping, does your child...

II. Does your child...

Section Break

V. This child often...

IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOUR CHILD MAY BE AT RISK OF SLEEP APNEA

SPEAK TO ONE OF OUR FRIENDLY TEAM MEMBERS TODAY!