Pediatric Sleep Questionnaire

Is your child struggling to sleep?
Take our pediatric sleep questionnaire to find out answers, and call us to schedule a consult so we can help!

Your Name*
Your E-mail Address*
Your Phone Number*
Does your child have trouble going to bed or falling asleep?
- Yes
- No
Awaken during the night and have trouble returning to sleep?
- Yes
- No
Does he or she tend to breathe through their mouth during the day or during sleep?
- Yes
- No
Have dry mouth or bad breath upon waking in the morning?
- Yes
- No
Have you noticed any of the following while your child is sleeping?
- Snoring, heavy or loud breathing?
- Break or pause in breathing
- Gasp, choke or struggle to breathe
- Restless or agitated sleep? Grinding teeth
- Abnormal head posture? (hyper-extension, etc.)
- Excessive sweating
- Wetting the bed
Have you noticed and of the following during the day?
- Difficulty waking
- Wakes with headache
- Groggy, tired, or "out of it"?
- Hyperactive
- Teachers commented
Child often:
- Does not seem to listen when spoken to directly
- Has difficulty organizing tasks
- Easily distracted by extraneous stimuli
- Fidgets with hands or feet or squirms in seat
- Interrupts or intrudes on others
Is your child frequently sick, have a history of sore throat, ear infections, sinus infections or allergies?
- Yes
- No
Stop growing at a normal rate at any time since birth? Or are they overweight?
- Yes
- No
Habits such as: pacifier/thumb sucking/lip biting, or other?
- First Choice
- Second Choice
- Third Choice
Initials
This field is for validation purposes and should be left unchanged.

Hoping to get a more restful night's sleep?

Contact our office to get evaluated by Dr. Galante and see if you need help with sleep apnea.

Schedule an Appointment Map & Driving Directions

Diagnosing Sleep Apnea

Learn more about Do you have obstructive sleep apnea (OSA)? Learn more about Should you get a sleep study evaluation? Learn more about The Airway Centric Relation Learn more about What is Sleep Apnea (OSA)? Learn more about Do you snore? Learn more about Pediatric Sleep Questionnaire Learn more about Sleep Hygiene Learn more about Benefits of Breathing Through Your Nose Learn more about The Older You Are, The Worse You Sleep Learn more about Three Pillars of Health Learn more about The Rich and Famous Snore and have Sleep Apnea Learn more about Drowsy Driving Learn more about Causes of Interrupted Sleep

Andrew P. Galante, DMD, MAGD

31-D Mountain Blvd
Warren, NJ 07059

Tel: Andrew P. Galante, DMD, MAGD Office Phone Number (908) 561-3939 Fax: (908) 561-3384

Dr. Galante provides high quality dentistry for patients in Warren, NJ & the surrounding areas to help them live healthier lives with great oral health! We offer various general & cosmetic dental treatments & help sleep apnea patients as well. Call today with any questions or to schedule an appointment.

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Serving Warren and the following nearby locations:

Watchung NJ
Stirling NJ
Greenbrook NJ
Basking Ridge NJ
Bridgewater NJ
North Plainfield NJ

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