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

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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

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I. While Sleeping, does your child...

II. Does your child...

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V. This child often...

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

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