Pediatric Sleep Questionnaire
Care That Goes Beyond
Screening Your Child's Sleep and Breathing
Healthy sleep plays an important role in a child’s growth and development. This questionnaire asks about your child’s snoring, breathing and daytime energy so Dr. Dhol can see if sleep or airway habits should be part of their orthodontic evaluation. It is used for screening only and is not a diagnosis.
Before You Start
- A parent or guardian should fill it out.
- Answer for the past month. “Usually” means more than half the time or more than half the nights.
- Choose “Don’t Know” if you are not sure.
Questions about this form? Call or text our South Surrey office at (604) 502-5155.