Please fill in where applicable.
Day Care: Days of week and hours of attendance:
Public School: Days of week and hours of attendance: Current Grade: Academic Performance: IEP Support? Behavioral issues in school? Extracurricular activities: Afterschool activities: Days of Week and hours of attendance: Scheduled evening activities: Days of Week and hours of attendance: Employment: Current employment (if applicable): Hours of work:
Name of drug Dose(strength & #pills/day)
Does your child sleep regularly in another household? If so, how many nights a month?
Does your child sleep in their own bedroom? If not, who else sleeps in the bedroom
1. What time does your child go to bed at night? blanks PM/AM
2. How much does your child’s bedtime and wake up time change from day to day for school nights Less than 15 mins. 15 to 30 mins. 30 to 60 mins. More than 60mins
3. How often does your child have difficulty falling asleep at night out of 5 nights? Never Not during the past month Less than once a week 1-2 times a week 3-4 times a week 5 or more times a week
3A. How much time does it usually take your child to fall asleep after going to bed? Hrs. Mins.
3B. What is the longest time it has taken your child to fall asleep after being put to bed? Hrs. Mins.
4. How often do night wakings occur? Once Twice 3 times or more None
4A. How often do night wakings occur? Never Not during the past month Less than once a week 1-2 times a week 3-4 times a week 5 or more times a week
4B. How much time does it usually take her/him to fall back to sleep after waking in the night? Hrs. Mins.
5. On average, how many hours does your child sleep on school nights? Hrs.
6. What time does your child wake up on school mornings? AM/PM
7. What time does your child’s school start? AM/PM
8. On how many school mornings does your child: Please choose one number.
10C. If your child naps on the weekday, how long is a typical nap? Hrs. Mins.
10D. What time(s) does your child nap? PM/AM TO PM/AM
Questions 11-18 refer to child's sleep during the last 1 month on Weekend/Vacation Nights:
Weekend Nights are considered:
11. What time does your child go to bed at night? PM/AM
12A. How much time does it usually take your child to fall asleep after going to bed? Hrs. Min.
12B. What is the longest time it has taken your child to fall asleep after being put to bed?Hrs. Min.
13B. How much time does it usually take her/him to fall back to sleep after waking in the night? Hrs. Mins
14. What time does your child wake up in the morning?PM/AM
17C. If your child naps, how long is a typical nap? Hrs. Mins.
17D. What time(s) does your child nap? PM/AM TO PM/AM
18. On average, how many hours does your child sleep on weekend nights? Hrs.
20. How much sleep do you think your child needs? Hrs. Mins.
Below is a list of questions about various sleep problems. For each question please think about the last month. Please answer all items the best you can, even if some of these questions do not apply to your child.
Please rate your child’s chances of falling asleep or dozing in each of the situations listed below. Think about a typical day: Please check one:
How concerned are you about your child’s sleep problem? Please pick a number on the scale below.