Dr. Whitlock

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:

    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know

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

    YesNoI Don't Know

    Does your child:

    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know

    Does your child:

    YesNoI Don't Know


    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:

    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know


    YesNoI Don't Know