This questionnaire has been compiled from multiple sources to best help us assess a pediatric patient's sleep. Please fill out all questions to the best of your knowledge. This information will become part of the medical record and is considered confidential.
Primary Care Physician (may be same as referring)
Total estimated amount of sleep on a weekday (including naps): hours mins.
Usual bedtime on weekday nights: Usual wake time on weekday mornings: mins.
Total estimated amount of sleep on a weekend day (including naps): hours mins.
Usual bedtime on weekend nights: Usual wake time on weekend mornings: mins.
General Sleep Information:
Past Medical History:
Child’s Medical History:
If your child has long-term medical problems, list the three that you think are the most important.
Current Sleep Symptoms:
Current Daytime Symptoms
Past Psychiatric History
Past Surgical History:
BEARS SLEEP SCREENING ALGORITHM
The “BEARS” instrument is divided into five major sleep domains, providing a comprehensive screen for the major
sleep disorders affecting children in the 2- to 18-year old range. Each sleep domain has a set of age appropriate “trigger
questions” for use in the clinical interview.
B = bedtime problems
E = excessive daytime sleepiness
A = awakenings during the night
R = regularity and duration of sleep
S = snoring
(P) Parent-directed question Does your child (P)
(C) Child-directed question Do you (C)
Source: “A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems” by Jodi A. Mindell and Judith A. Owens; Lippincott Williams & Wilkins
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Sleep and Breathing Patterns in Childhood
Pediatric Sleep Questionnaire (PSQ)
1.While sleeping, does your child…