Pediatric Sleep Questionnaire (Age 16 years old) Patient Name Date of Birth Doctor Date Completed Reason for visit Referring Doctor Please mark if you experience any of the following symptoms: Snoring.

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How to fill out the Pediatric Sleep Questionnaire online

This guide provides comprehensive and user-friendly instructions on filling out the Pediatric Sleep Questionnaire for individuals aged 16 years and younger. By following these steps, you will ensure that all necessary information is accurately captured to support your child's health assessment.

Follow the steps to complete the Pediatric Sleep Questionnaire effectively.

  1. Click ‘Get Form’ button to obtain the Pediatric Sleep Questionnaire and open it in the viewing application.
  2. Begin by filling in the patient’s name and date of birth in the designated fields at the top of the form. This essential information identifies the child for whom the questionnaire is being completed.
  3. Next, enter the doctor’s name and the date the questionnaire was completed. This helps ensure that the right medical professional is associated with the assessment.
  4. Provide the reason for the visit and the referring doctor’s name, if applicable. This contextual information is crucial for proper evaluation.
  5. In the symptoms section, mark 'yes' or 'no' next to each symptom experienced by the child, such as snoring or daytime sleepiness. Be thorough to accurately reflect the child's experience.
  6. Move to the sleep schedule section, where you'll input the child's bedtime, wake time, and other related questions. Clearly indicate the information for both weekdays and weekends.
  7. Fill out the section on additional symptoms or conditions by checking the relevant boxes. This part helps highlight any potential health concerns.
  8. Document any medications for sleep that the child has tried, as well as the dates and locations of any previous sleep studies. This information is pertinent for ongoing treatment evaluations.
  9. Finally, list the names of any doctors you wish to send today's note to, ensuring that all relevant medical professionals are informed.
  10. Review the completed questionnaire for accuracy, then save your changes. Afterward, download, print, or share the form as necessary.

Start filling out the Pediatric Sleep Questionnaire online today.

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What to expect at a pediatric sleep study?

Small plastic prongs at the nose will measure your child's exhaled air. Elastic or cloth belts will be placed on your child's chest and stomach, usually over her pajamas. Stick-on electrodes will be placed on your child's face and chest to measure eye movements, heart rate and muscle tone during sleep.

A score of 10 or more is considered sleepy. A score of 18 or more is very sleepy. If you score 10 or more on this test, you should consider whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to see a sleep specialist. These issues should be discussed with your personal physician.

Use the following scale to choose the most appropriate number for each situation. 0=would never doze or sleep 1=slight chance of dozing or sleeping 2=moderate chance of dozing or sleeping 3=high chance of dozing or sleeping.

The PSQ is a 22-item questionnaire developed and validated at the University of Michigan as a research tool to identify children at risk for sleep-related breathing disorders. It includes items intended to measure childhood sleep-related breathing disorder with subscores for snoring, sleepiness, and behavior.

The Pediatric Sleep Questionnaire (PSQ) scores 22 items that investigate presence and intensity of snoring, presence of obstructive apneas and breathing difficulties, sleepiness, and other symptoms that correlate with pediatric OSA.

Paediatric Sleep Questionnaire (PSQ) For children aged 2–18 years, the scale has good internal consistency (α =0.88) with a sensitivity of 0.85 and specificity of 0.87 for identifying children with sleep related breathing disorders.

Each scored question is rated on a 3-point scale as occurring “usually” (i.e., 5–7 times within the past week), “sometimes” (i.e., 2–4 times within the past week), or “rarely” (i.e., never or 1 time within the past week).

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