Pediatric Sleep Apnea Questionnaire

Constant runny nose? (Yes/No)

Cardiac disease (Yes/No)

Arthritis (Yes/No)

Does your child have a diagnosed behavioral problem (Yes/No)

The following questions can be answered by “never”, ”seldom”, ”sometimes”, ”often”, or “almost always”.

Does you child go to bed unwillingly? _______________

Does your child express fear or worries before going to bed? _______________

Does your child complain about difficulties going to sleep? _______________

Does your child complain of difficulties falling asleep at night? _______________

Is your child a restless sleeper? _______________

Does your child wake up at night? _______________

Does your child get up to go to the bathroom during the night? _______________

While asleep, does your child ever sit up in bed? _______________

Is your child a mouth-breather? _______________

Does your child have nightmares? _______________

Does your child have problems with bed wetting? _______________

Does your child snore during sleep? _______________

Have your observed your child sleep walking? _______________

Does your child sweat more than usual during sleep? _______________

Does your child snore at least half the night? _______________

Does your child have difficulties breathing during sleep? _______________

Do you ever shake your child to make them breathe again when asleep? ______________

Does your child stop breathing during sleep? ______________

Is your child easy to wake up in the morning? _______________

Is your child sleepy when they wake up in the morning? _______________

Is your child sleepy during the day? _______________

Does your child complain about tiredness/sleepiness in the afternoons? ______________

How long does your child sleep at night? _______________

At what time does your child go to bed? _______________

How long does your child sleep during the day? ________________

When answering the next six questions, please use “not at all”, “sometimes”, or “very much”

Does the behavior described in each sentence characterize your child? :

1. Has difficulties concentrating during school activities? _______________

2. Has difficulties in maintaining attention on one task for a long time? __________

3. Has a tendency to act carelessly and not notice details? _______________

4. Is easily distracted from his/her activities (u noise, etc.) _______________

5. Is restless, jumpy? _______________

6. Many times acts impulsively? _______________