Airway and Sleep Questionnaire

Healthy sleep is just as important to your child’s overall well-being as healthy teeth and gums. Sleep related breathing issues, such as snoring, pauses in breathing, or restless sleep, can affect growth, behavior, learning and even oral health.

As part of your child’s dental care, we ask that you complete this short sleep questionnaire.

Please observe your child while sleeping on a few different nights to answer as accurately as possible.

While sleeping, does your child…

Snore more than half the time? □ Yes □ No

Always snore? □ Yes □ No

Snore loudly? □ Yes □ No

Have “heavy” or loud breathing? □ Yes □ No

Have trouble breathing, or struggle to breathe? □ Yes □ No

Have you ever…

Seen your child stop breathing during the night? □ Yes □ No

Does your child…

Tend to breathe through the mouth during the day? □ Yes □ No

Have a dry mouth on waking up in the morning? □ Yes □ No

Occasionally wet the bed? □ Yes □ No

Wake up feeling unrefreshed in the morning? □ Yes □ No

Have a problem with sleepiness during the day? □ Yes □ No

Has a teacher or other supervisor commented that your child appears sleepy during the day?

□ Yes □ No

Is it hard to wake your child up in the morning? □ Yes □ No

Does your child wake up with headaches in the morning? □ Yes □ No

Did your child stop growing at a normal rate at any time since birth? □ Yes □ No

Is your child overweight? □ Yes □ No

This child often…

Does not seem to listen when spoken to directly? □ Yes □ No

Has difficulty organizing task and activities? □ Yes □ No

Is easily distracted by extraneous stimuli? □ Yes □ No

Fidgets with hands or feet or squirms in seat? □ Yes □ No

Is ‘on the go’ or often acts as if ‘driven by a motor’? □ Yes □ No

Interrupts or intrudes on others (e.g. butts into conversations or games)? □ Yes □ No

Total number of “Yes” responses

If your child has 8 or more “positive” (yes) answers, it suggests there may be a significant sleep concern. We recommend you schedule an appointment with your child’s pediatrician to discuss results and determine if further testing or treatment is necessary.