Myosleep Kids Questionnaire

Patient Name

Date of Birth

Today's Date

1. Going To Sleep

Does your child have any problems going to bed or falling asleep?

Yes No Not Sure

Does your child tend to have an irregular bedtime?

Yes No Not Sure

Does your child tend to have an irregular wake time?

Yes No Not Sure

Does your child’s bedtime/wake time differ greatly between weekdays and weekends?

Yes No Not Sure

2. While Sleeping

Does your child wake up often during the night after falling asleep?

Yes No Not Sure

Does your child have their mouth open while sleeping?

Yes No Not Sure

Does your child have heavy or loud breathing habits while asleep?

Yes No Not Sure

Does your child snore for more than half of the night’s sleep duration?

Yes No Not Sure

Does your child snore for more than three or four nights out of the week?

Yes No Not Sure

Does your child snore every night?

Yes No Not Sure

Does your child snore loudly?

Yes No Not Sure

Does your child have difficulty breathing at night while sleeping?

Yes No Not Sure

Does your child ever stop breathing while sleeping?

Yes No Not Sure

Does your child have regular nightmares, sleep walk or have any other unusual sleep behaviours?

Yes No Not Sure

Does your child occasionally wet the bed?

Yes No Not Sure

3. While Awake

Does your child have a dry mouth when they wake up in the morning?

Yes No Not Sure

Does your child find it difficult to wake in the morning?

Yes No Not Sure

Does your child wake up feeling unrefreshed in the morning?

Yes No Not Sure

Does your child seem overly tired or take excessive naps during the day for their age?

Yes No Not Sure

Does your child wake up with headaches in the morning?

Yes No Not Sure

Do you think your child is failing to get enough sleep for his/her age?

Yes No Not Sure

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

Yes No Not Sure

Does your child tend to breathe through the mouth while awake?

Yes No Not Sure

Is your child’s overall growth slower than the average child for their age?

Yes No Not Sure

Is your child overweight?

Yes No Not Sure

Does your child have difficulty organising tasks and activities for their age?

Yes No Not Sure

Does your child appear to not listen when spoken to directly?

Yes No Not Sure

Does your child get easily distracted, fidget or struggle to sit still?

Yes No Not Sure

Is your child hyperactive?

Yes No Not Sure

Please provide any additional feedback that may be relevant to your child’s sleep habits:

Parent Name/s

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Myosleep Kids Questionnaire

1. Going To Sleep

2. While Sleeping

3. While Awake

Kewaskum Family Dentistry