Patient Sleep Questionnaire

Pediatric Sleep Questionnaire (Age < 16 yrs)

DSM SLEEP SPECIALISTS, PLC SLEEP MEDICINE SLEEP QUESTIONNAIRE
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Sleep Physician
Date Completed

MonthDayYear
Date
Please mark if you experience any of the following symptoms:*

SnoringStop breathing during sleepDaytime sleepinessMorning headacheDry mouthSleep walkingSleep talkingComplex behaviors during sleep (eating, completing tasks, driving, etc.)Grinding of teethBedwetting during sleepRestless legs syndrome (creepy crawly feeling of the legs/arms that occur at night and with inactivity. Relieved by moving)Vivid, dream-like images that occur while falling asleep or waking upInability to move body after waking up (Sleep Paralysis)Episodes of muscular weakness that are triggered by emotion (i.e., laughing, crying, stress)Acting out dreams violentlyPrevious diagnose of sleep apnea by sleep study testing
If sleep walking, injury to self or others while sleepwalking
If acting out dreams violently, have you ever injured yourself?

YesNo
Sleep Schedule
Bedtime (Weekdays)*

Hour Minutes

AM/PM Option
Bedtime (Weekends)*

Hour Minutes

AM/PM Option
Wake time (Weekdays)*

Hour Minutes

AM/PM Option
Wake time (Weekends)*

Hour Minutes

AM/PM Option
How long does it take for you to fall asleep?*
How many times do you wake up per night? *
How long does it take for you to get back to sleep?*
How many hours of sleep not including naps do you have per day? *
How many times do you nap per day and how long is each nap? *
Do you have a bedtime routine? *
PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS/CONDITIONS:*

Tiredness/FatigueCardiac diseaseAnxietyBruising of the skinSwelling of the legs and/or bodyDepressionSinus problemsHeart DiseaseStrokeBehavioral problemsLiver diseaseSeizuresNeck PainKidney DiseaseDiabetesShortness of breathBack PainThyroid problemsCoughDeclining school gradesLow iron (anemia)Home oxygen useUse of electronics before bedtimeCPAP/BiPAP useAsthmaAcid reflux
Please list any medications (prescribed and over the counter) for sleep that you have tried:*
Please list date(s) and location(s) of previous sleep studytesting*
Please list the names of any doctors you would like to have today’s note sent to:
Should be Empty:

Pediatric Sleep Questionnaire (Age < 16 yrs)

Sleep Schedule