Pediatric Sleep Questionnaire

Patients First & Last Name
On October 31, 2017, the American Dental Association created a mandate on sleep-related breathing disorder as follows:

“The policy emphasizes the dentists' role in screening sleep-related breathing disorders as significant since dentists are often the first to identify symptoms and discuss medical and dental history with the patient.  The policy recognizes the importance of referral of at-risk patients to a physician for diagnosis and treatment…In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development or other risk factors that may lead to airway issues. If risk is determined, intervention through medical or dental referral or treatment may be appropriate to help treat the disorder and/or develop an optimal physiologic airway and breathing pattern”.

It is our responsibility and privilege as your child’s primary dental provider to screen for these problems. We at Bridger Children’s Dentistry are committed to your child’s oral-facial and airway health.

While sleeping does your child…

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?

Does your child…

Tend to breathe through the mouth during the day?
Have a dry mouth on waking up in the morning?
Occasionally wet the bed?
Wake up feeling un-refreshed in the morning?
Have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child up in the morning?
Does your child wake up with headaches in the morning?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?

This child often…

Does not seem to listen when spoken to directly
Has difficulty organizing tasks
Is easily distracted by extraneous stimuli
Fidgets with hands or feet or squirms in seat
Is “on the go” or often acts as if “driven by a motor”
Interrupts or intrudes on others (e.g. butts into conversations or games)