Child Sleep Questionnaire
Children’s National Medical Center
Child Sleep Questionnaire
(2 Years – 18 Years)
Patient’s Name________________________________
Date of Birth: _____/_____/_____
Date_____________________
Sex:
_____male
_____female
Name of Person Completing Questionnaire________________________________________________
Parent/Guardian’s Name______________________________________________________________
Pediatrician/Primary Care Physician__________________________
Phone #__________________
Referring Health Care Provider______________________________
Phone #__________________
Current Height: ______________
Current Weight: _____________
Please list all medications your child is currently taking, both prescription and over the counter
Medication
Purpose
Dose/How Often
Brief Medical History (circle all that apply):
1.
Prematurity
Asthma
Infant Apnea
Seizures
Muscular dystrophy
Tonsillectomy/adenoidectomy
Cerebral Palsy
Tracheostomy
Enlarged tonsils/adenoids
Gastroesophageal reflux
Bronchopulmonary Dysplasia (BPD)
Spina bifida
Psychiatric disorder
Developmental disorder (Down Syndrome, Autism, Language delay, etc.)
Other________________________________________________________________________
2. Has your infant ever been diagnosed with a sleep disorder? Yes
No (if yes please specify) ______
3. Does your child use Oxygen therapy?
Yes
No
4. Does your child use CPAP/BiPAP therapy?
Yes
No
5. Has your child ever been prescribed caffeine/theophylline? Yes
No
6. Has your child ever been on a home apnea monitor?
Yes
No
7. Was your child born full term?
Yes
No
7a. If no, how many weeks/months premature?
_________ weeks
_______ months
8. Does your child have any symptoms of reflux (heart burn, frequent spit-ups after meals)
Yes
No
8a. If yes, is s/he currently medicated for this or have you been advised to take precautions during/after
meals? Please explain: ____________________________________________________________.
9. Has your child ever turned blue?
Yes ___
No ___
10. Has your child ever required stimulation to resume breathing?
Never ____ Occasionally ____ Frequently _____
Rev12/09
1
Child Sleep Questionnaire
Please think about the last 3 months:
11. What time does your child go to bed on week nights (school nights)? __________ pm/am
12. What time does your child wake up on weekday mornings? __________ pm/am
13. On average, how many hours does your child sleep on school nights?
14. On how many weekday (school) mornings does your child:
Use an alarm to wake up? ______
_________hours
Wake up on his/her own? ________
Is awakened by a parent, sibling or other caretaker? _________
15. How much does your child’s bedtime and wake up time change from night to night?
Less than 15 min. ___
15 to 30 min. ____
30 – 60 min. ___
More than 60 min. ___
Weekend/Vacation Sleep Schedule
16. What time does your child go to bed on weekends (non-school nights)?
_________pm / am
17. What time does your child wake up on weekends (non-school mornings)?
_________pm / am
18. On average, how many hours does your child sleep on weekend (non-school) nights _________hours
Never
Not
during
the past
month
Less
than
once a
week
Once or
twice a
week
3 or 4
times a
week
5 or
more
times a
week
19. How often does your child have difficulty
waking up in the morning?`
20. How often does your child nap?
21. If your child were to set his/her own schedule, which of the following would s/he prefer (think about actual sleep habits on
summers and weekends)
Go to bed and wake up early ___
Go to bed late and wake up late ___
Has no preference ___
22. Has your child ever taken over-the-counter or prescription medications at bedtime that help him/her to calm down and/or
fall asleep?
Yes ___
No ___
22a. If yes, please list medications and dosage:________________________________________________________
23. Which of the following items does your child have in her/his bedroom? _____ Television _____VCR
_____Computer
_______ Internet Access
____Computer
______ Video Game System
24. Does your child drink caffeinated beverages or eat foods that contain caffeine?
Yes
No
If yes, please describe type and amount_______________________________________________________________
25. Does your child resist going to bed?
26. How often is there a regular bedtime
routine in your home?
27. After bedtime, does your child call you
back to the bedroom more than 2 times?
Rev12/09
2
Child Sleep Questionnaire
PLEASE THINK ABOUT THE LAST 3 WEEKS:
Never
Not
during
the past
month
Less
than
once a
week
Once or
twice a
week
3 or 4
times a
week
5or
more
times a
week
28. Are bedtime and the hour leading up to it
a stressful time?
29. Does your child have difficulty falling
asleep at night?
29a. What is the longest time it has taken your child to fall asleep after being put to bed?
29b. How much time does it usually take him/her to fall sleep after being put to bed?
_______ minutes
_______ minutes
30. Does your child wake up in the middle of
the night and take 10 or more minutes to
fall back to sleep?
31. What is the longest time it has taken your child to fall back to sleep after a night awakening? _______ minutes
32. Does your child grind his/her teeth while
asleep?
33. Does your child sleep in a caretaker’s bed?
34. Does your child share a bedroom with
another family member?
35. Does your child have difficulty waking up
in the morning?
36. Does your child nap?
36a. If yes, how long does your child usually nap ____________
37. What are the chances that your child would doze in each of the following situations? (CHECK ONE BOX IN EACH ROW)
Situation
Would
never
doze
Slight
chance of
dozing
Moderate
chance of
dozing
High
chance of
dozing
37a. In school
37b. Watching T.V.
37c. Sitting quietly in public (in church, at a movie or lecture)
37d. Riding in a car
37e. Lying down to re
st in the afternoon
37f. While talking to someone
37g. While playing with friends
PLEASE THINK ABOUT THE LAST 3 WEEKS:
Never
Not
during
the past
month
Less
than
once a
week
Once or
twice a
week
3 or 4
times a
week
5 or
more
times a
week
38. Does your child wake up screaming,
agitated, or confused?
38a. If yes, does s/he calm down after being comforted?
Yes
No
38b. If yes, does s/he recall the awakening the next morning?
Yes
No
39. Does your child sleepwalk?
39a. If yes, during sleep walking episodes has s/he ever (check all that apply):
been at risk of injury___
Rev12/09
attempted to leave the bedroom___
been injured ___
attempted to go outside the home___
3
Child Sleep Questionnaire
PLEASE THINK ABOUT THE LAST 3 WEEKS:
Never
Not
during
the past
month
Less
than
once a
week
Once or
twice a
week
3 or 4
times a
week
5 or
more
times a
week
40. Does your child have repetitive
movements during sleep, for example
(check all that apply):
leg jerks ___
head banging ___
lip smacking ___
other______________
40a. If yes, how often have these
movements occurred?
41. Does your child report having nightmares
or frightening dreams?
42. Does your child report that s/he couldn’t
move when s/he tried to get up.
43. Does your child fall asleep suddenly at
unexpected times?
44. Does your child report having very real
dreams that there is a person or animal in
his/her room?
45. Does your child complain of leg pain or
discomfort or feel the need to move
his/her legs when at rest?
46. Does your child snore?
47. My child’s snoring can be heard (check all that apply):
throughout the house ___
in other bedrooms on the same floor ___
one room away ___
48. While your child is sleeping, does s/he (check all that apply):
struggle to breathe___ hold his/her breath___ stop breathing for short periods of time___
gasp___
none of these___
49. If yes, how often do these breathing
problems occur?
50. Is your child a restless sleeper?
51. Does your child wet the bed at night?
51a. If your child wets the bed, has your child ever been completely dry for more than a week?
Yes ___
No ___
52. Does your child grind his/her teeth while
asleep?
53. Does your child share a bedroom with
another family member?
54. Do you observe your child while s/he
sleeps?
55. How concerned are you about your child’s sleep problem? (please place an X between the asterisks)
*__________________________________________*
Not at all the concerned
Rev12/09
Extremely concerned
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Child Sleep Questionnaire
TWO-WEEK SLEEP RECORD
PATIENT’S NAME _______________________________
PATIENT’S DATE OF BIRTH______________
PARENT’S NAME_____________________
ADDRESS_______________________________________
DATE OF SLEEP RECORD: FROM________TO_________
TELEPHONE NUMBER_________________
INSTRUCTIONS:
Leave blank the periods your child is awake.
Mon
sleep
Tue
nap
sleep
Fill in the times your child is
Asleep with shaded boxes.
Mark your child’s bedtimes with downward-pointing arrows.
nap
sleep
sleep
Mark the times your child gets up in the morning and
after naps with arrows pointing upwards.
_________________________________________
Day
M
M
I
I
D
D
N
N
I ________________________AM_________________________ _PM____________________________________________________ I
G
G
H
H
T
2:00
4:00
6:00
8:00
10:00
Noon
2:00
4:00
6:00
8:00
10:00
T
_____________________________________
SPECIAL OBSERVATIONS AND NOTES:____________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Rev12/09
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