Child- Engish

Pre-Registration Information

Sleep Disorder Center Pediatric Questionnaire

Please complete this questionnaire and return it to the physician who interviews you and your child at the time of the initial evaluation.

In answering the questions are as complete as possible. The more information that is given to more complete Will be the evaluation of your child’s condition.

Use the full space available in the feilds to complete the detailed answers or to add additional information which is relevant.

Select the most appropriate answers in the questionnaire. DK = Don't Know NA = Not Applicable

The sleep disorder center physicians will go over the answers with you. We look forward to being able to evaluate your child’s problem and to be able to provide therapeutic advice.

EPWORTH SCALE   How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you “Have Not’ done some of these recently, try to work out how they would affected you. Use the following scale to choose the most appropriate number of each situation:  
0 No Chance of Dozing
1 Slight Chance of Dozing
2 Moderate Chance of Dozing
3 High Chance of Dozing

STOP-BANG Sleep Apnea Questionaire