Dr. Shab Krish DDS, MS

1005 Long Prairie Road, Suite 300

Flower Mound, TX 75022

972-538-3777

TMJ & Sleep Therapy Centre of North Texas

Providing Non-Surgical Therapies for Craniofacial Pain, TMJ Disorder & Sleep Disordered Breathing

Pediatric Sleep Evaluation Questionnaire

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.

Date:

Demographic Information

Child's Last Name:
Child's First Name
Child's DOB:
Child's Age:
Gender:
Height:
Weight:
School Grade:
Address:
City:
State:
Zip Code:
Phone:
Email:

Physician Information

Referring Physician:

Name:
Phone:
Address:

Primary Care Physician (may be same as referring)

Name:
Assistant:
Address:

Sleep Problems:

What are your major concerns about your child's sleep?
What have you previously tried to help this problem?

Sleep Times:

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.

Nap Times:

Number of days each week that your child takes a nap:
Nap Times (from when to when):

General Sleep Information:

Is there a regular bedtime?
Does the child have his/her own bedroom?
Does the child have his/her own bed?
Is there a parent present when your child falls asleep?
Does the child resist going to bed?
Does the child have difficulty falling asleep?
Does the child awaken during the night?
Is this a problem?
If awakening at night, does the child have difficulty returning to sleep?
Is the child difficult to awaken in the morning?
Is the child a poor sleeper?

Past Medical History:

Pregnancy/Delivery

Pregnancy:
Delivery:
Child's birth weight:
Is this an only child?
If no, what number child is this?

Child’s Medical History:

Frequent nasal congestion?
Trouble breathing through his/her nose?
Sinus problems?
Chronic bronchitis or cough?
Environmental allergies?
Asthma
Frequent colds or flus?
Frequent strep throat infections?
Difficulty swallowing?
Acid reflux (gastroesophageal reflux)?
Poor or delayed growth?
Excessive weight?
Hearing problems?
Speech problems?
Vision problems?
Seizures/ Epilepsy?
Morning headaches?
Cerebral palsy?
Heart disease?
High blood pressure?
Sickle cell disease?
Genetic disease?
Chromosome problem (e.g., Down's)?
Skeleton problem (e.g., dwarfism)?
Craniofacial disorder (e.g., Pierre-Robin)?
Thyroid problem?
Eczema (itchy skin)?
Pain?

If your child has long-term medical problems, list the three that you think are the most important.

1.
2.
3.

Current Sleep Symptoms:

Difficult breathing when asleep?
Stops breathing during sleep?
Snores?
Restless sleep?
Sweating when sleeping?
Daytime sleepiness?
Poor appetite?
Nightmares?
Sleepwalking?
Sleep talking?
Screaming during sleep?
Leg kicking during sleep?
Waking up at night?
Getting out of bed at night?
Trouble staying in his/her bed?
Resistance going to bed?
Teeth grinding?
Uncomfortable “creepy-crawly” feeling in his/her legs?
Bed wetting?

Current Daytime Symptoms

Trouble getting up in the morning?
Falls asleep at school?
Naps after school?
Daytime sleepiness?
Feels weak or loses control of his//her muscles with strong emotions?
Reports being unable to move when falling asleep or upon waking?
Reports frightening visual images before falling asleep or upon waking?

Family History:

Mother:

Age
Education:
Occupation:

Father:

Age
Education:
Occupation:
Other persons living in the home:
Does anyone in the family have a sleep disorder?
If yes, who and what disorder?

Past Psychiatric History

Autism?
Developmental Delay?
Hyperactivity/ADHD?
Anxiety/Panic attacks?
Obsessive Compulsive Disorder?
Depression?
Learning Disabilities?
Drug use/abuse?
Behavioral Disorder?
Psychiatric Admission?

Past Surgical History:

Has your child ever had his/her tonsils removed?
Has your child ever had his/her adenoids removed?
Has your child ever had ear tubes?
What other surgeries has your child had (include age when surgery performed)?

Medications:

Medication Name

Dose

How often?

Medication Allergies:
Environmental Allergies:

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

Symptom Age Toddler/Preschool (2-5 years) Age School Age (6-12 years) Age Adolescent (13-18 years)
1. Bedtime Problems
Does your child have any problems going to bed? (P)
Does your child have any problems at bedtime? (P)
Do you have any problems going to bed? (C)
Do you have any problems falling asleep at bedtime? (C)
2. Excessive Daytime Sleepiness
Does your child seem overtired or sleepy a lot during the day? (P)
Does your child have difficulty waking in the morning; seem sleepy during the day or take naps? (P)
Do you feel tired a lot? (C)
Do you feel sleepy a lot during the day? (C)
In School? (C)
While Driving? (C)
3. Awakenings during the night
Does your child wake up a lot at night? (P)
Does your child seem to wake up a lot at night? (P)
Any sleepwalking or nightmares? (P)
Do you wake up a lot at night? (C)
Have trouble getting back to sleep? (C)
Do you wake up a lot at night? (C)
Have trouble getting back to sleep? (C)
4. Regularity and duration of sleep
Does your child have a regular bedtime and wake time? (P)
What are they? (P)
What time does your child go to bed and get up on school days? (P)
Weekends? (P)
Do you think he/she is getting enough sleep? (P)
What time do you usually go to bed on school nights? (C)
Weekends? (C)
How much sleep do you usually get? (C)
5. Snoring
Does your child snore a lot or have difficult breathing at night? (P)
Does your child have loud or nightly snoring or any breathing difficulties at night? (P)
Does your teenager snore loudly or nightly? (P)

(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

Patient/Parent Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Sleep and Breathing Patterns in Childhood Pediatric Sleep Questionnaire (PSQ)

1.While sleeping, does your child…
a. Snore more than half the time?
b. Always snore?
c. Snore loudly?
d. Have “heavy” or loud breathing?
e. Have trouble breathing or struggle to breathe?
f. Have you ever seen your child stop breathing during the night?
2.Does your child…
a.Tend to breathe through their mouth during the day?
b.Have a dry mouth on waking in the morning?
c. Occasionally wet the bed?
d. Wake up feeling unrefreshed during the day?
e. Have a teacher or other supervisor who commented that Your child sleeps during the day?
f. Find it hard to wake up in the morning?
g. Wake up with headaches in the morning?
3.Did your child stop growing at a normal rate at any time since birth?
4.Is your child overweight?
5.This child often…
a.Does not seem to listen when spoken to directly
b. Has difficulty organizing tasks and activities
c. Is easily distracted by extraneous stimuli
d. Fidgets with hands or feet or squirms in seat
e. Is ‘on the go’ or often acts as if ‘driven by a motor’
f. Interrupts or intrudes on other (e.g. butts into conversations or games)