Pediatric Sleep Apnea Questionnaire

Instructions:


Please answer the questions on the following pages regarding the behavior of your child during

sleep and wakefulness. The questions apply to how your child acts in general, not necessarily

during the past few days since these may not have been typical if your child has not been well. If

you are not sure how to answer any question, please feel free to ask your husband or wife, child, or

physician for help. When you see the word "usually" it means "more than half the time" or "on more

than half the nights."



Name of person completing this questionnaire: __________________________________________

Relationship to the child? ____________________________________________________________



A. Nighttime and sleep behavior:

WHILE SLEEPING, DOES YOUR CHILD … Yes No Don't Know

… ever snore?

… snore more than half the time?

… always snore?

… snore loudly?

… have "heavy" or loud breathing?

… have trouble breathing, or struggle to breathe?



HAVE YOU EVER … …

seen your child stop breathing during the night?

If so, please describe what has happened:



… been concerned about your child's breathing during sleep?

… had to shake your sleeping child to get him or her to breathe, or wake

up and breathe?

… seen your child wake up with a snorting sound?





DOES YOUR CHILD

… have restless sleep?

… describe restlessness of the legs when in bed?

… have "growing pains" (unexplained leg pains)?

… have "growing pains" that are worst in bed?





WHILE YOUR CHILD SLEEPS, HAVE YOU SEEN

… brief kicks of one leg or both legs?

… repeated kicks or jerks of the legs at regular intervals

(i.e., about every 20 to 40 seconds)?







AT NIGHT, DOES YOUR CHILD USUALLY



… become sweaty, or do the pajamas usually become wet with

perspiration?

Does your child usually sleep with the mouth open?

Is your child's nose usually congested or "stuffed" at night?

Do any allergies affect your child's ability to breathe through the nose?



DOES YOUR CHILD

… tend to breathe through the mouth during the day?

… have a dry mouth on waking up in the morning?

… complain of an upset stomach at night?

… get a burning feeling in the throat at night?

… grind his or her teeth at night?

… occasionally wet the bed?





B. Daytime behavior and other possible problems:

DOES YOUR CHILD … Yes No Don't Know

… wake up feeling unrefreshed in the morning?

… have a problem with sleepiness during the day?

… complain that he or she feels sleepy during the day?



Has a teacher or other supervisor commented that your child appears

sleepy during the day?

Does your child usually take a nap during the day?

Is it hard to wake your child up in the morning?

Does your child wake up with headaches in the morning?

Does your child get a headache at least once a month, on average?