Pediatric Sleep Questionnaire

A short questionnaire about your child’s sleep habits and daytime energy. Complete it if our team has asked you to.

Dentist and a smiling child patient during a pediatric sleep and airway screening.

Pediatric Sleep Questionnaire (Screening)

This field is for validation purposes and should be left unchanged.
Date of birth(Required)
Date that you are completing the questionnaire(Required)

Instructions: Please answer the questions about how your child IN THE PAST MONTH. Circle the correct response or print your answers in the space provided. “Y” means “yes,” “N” means “no,” and “DK” means “don't know.” For this questionnaire, the word “usually” means “more than half the time” or “on more than half the nights.”

Please answer the following questions as they pertain to your child in the past month.

1. 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 breath?
2. Have you ever seen your child stop breathing during the night?

3. 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?

4. Does your child:

Wake up feeling unrefreshed in the morning?
Have a problem with sleepiness during the day?
5. Has a teacher or other supervisor commented that your child appears sleepy during the day?
6. Is it hard to wake your child up in the morning?
7. Does your child wake up with headaches in the morning?
8. Did your child stop growing at a normal rate at any time since birth?
9. Is your child overweight?

10. This child often:

Does not seem to listen when spoken to directly
Has difficulty organizing tasks and activities
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 (eg butts into conversations or games)

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zeina issa
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I would like to express my sincere appreciation to the entire medical team at Appolonia Clinic for their punctuality, outstanding service, exceptional care, and remarkable attention to patients. A special thank you goes to Dr. Zahar for the outstanding care and dedication shown to my son, and to Nurse Viola for her kindness and professionalism. The clinic is exceptionally clean, welcoming, and caring—it truly feels like a second home. I would also like to extend my gratitude to the reception team for their excellent follow-up and appointment reminders. In particular, I would like to thank Mr. Tareq and Mr. Issa for their outstanding support, attention, and professionalism. I am truly grateful for the wonderful experience and highly appreciate the efforts of everyone involved.
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annamantony
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We are really happy with this place and thanks to all the staff who is working there 🙏🏻
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Valerie Sonley
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Love this Dentist Office ! Everyone is so friendly, The office staff are amazing and the dentists are fabulous, so gentle and soft handed .
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NICK NECHIFOR
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Excellent care for your dental needs all the time. My family is very happy! We have been with them close to 15 years now. I have moved away from Edmonton, but I couldn’t leave the team from Apollonia!!
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Dion Chalifoux
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Seem to be very quick painless, depending on what you get done and after the freezing, there’s a bit of pain not at all while you’re there keep up the great work and I will probably see you again. Thank you.
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Jason Wong
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Excellent service!
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Cheysser Magcasi
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Thank you Jen, Venus and Dr. B. Lee for making my visits always comfortable. I always dreaded going to the dental office, but thank you for changing that! I'm happy that I found this clinic. Truly a gem ❤️
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Alejandra Saavedra- Edm
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Loved my visit, Dr. Lee is very friendly and takes time to answer any question you may have. The people in the office are great. Would recomend!
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Brad MacDonald
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If you’re unsure about your current dentist or are looking for a new one don’t look any further Dr Brendan Lee is awesome he makes you feel comfortable straight away and happy you went to the dentist Oh and the rest of the staff is just as great
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Roxanne J
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Dr.Lee is the best dentist

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Conveniently located just off Whitemud Drive in the Tamarack / Larkspur area of South East Edmonton. Plenty of free parking.

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Dentist welcoming a patient at Apollonia Dental Clinic
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Child patient smiling in the dental chair at Apollonia Dental Clinic Edmonton
Dentist providing dental care to a child at Apollonia Dental Clinic in Edmonton

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canadian dental association college of regsitered dental hygenists college of alberta dental assistants alberta dental association college the canadian dental hygenists association american academy of dental sleep medicine canadian dental association college of regsitered dental hygenists college of alberta dental assistants alberta dental association college the canadian dental hygenists association american academy of dental sleep medicine

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