Pediatric Sleep Questionnaire (Screening) Instructions: Please answer the questions about how your child IN THE PAST MONTH. Circle the correct response or print your answers in the space provided. “Y” means “yes,” “N” means “no,” and “DK” means “don’t know.” For this questionnaire, the word “usually” means “more than half the time” or “on more than half the nights.” Please answer the following questions as they pertain to your child in the past month. While sleeping, does your child: Snore more than half the time?YesNoI Don't Know Always snore?YesNoI Don't Know Snore loudly?YesNoI Don't Know Have “heavy” or loud breathing?YesNoI Don't Know Have trouble breathing, or struggle to breath?YesNoI Don't Know Have you ever seen your child stop breathing during the night? YesNoI Don't Know Does your child: Tend to breathe through the mouth during the day? YesNoI Don't Know Have a dry mouth on waking up in the morning?YesNoI Don't Know Occasionally wet the bed?YesNoI Don't Know Does your child: Wake up feeling unrefreshed in the morning?YesNoI Don't Know Have a problem with sleepiness during the day?YesNoI Don't Know Has a teacher or other supervisor commented that your child appears sleepy during the day? YesNoI Don't Know Is it hard to wake your child up in the morning? YesNoI Don't Know Does your child wake up with headaches in the morning? YesNoI Don't Know Did your child stop growing at a normal rate at any time since birth? YesNoI Don't Know Is your child overweight? YesNoI Don't Know This child often: Does not seem to listen when spoken to directly YesNoI Don't Know Has difficulty organizing tasks and activitiesYesNoI Don't Know Is easily distracted by extraneous stimuli YesNoI Don't Know Fidgets with hands or feet, or squirms in seat YesNoI Don't Know Is “on the go” or often acts as if “driven by a motor” YesNoI Don't Know Interrupts or intrudes on others (eg butts into conversations or games)YesNoI Don't Know
