• Child Sleep Evaluation Questionnaire

  • DIRECTIONS

    Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child.

  • CHILD’S INFORMATION

  •  /  /
    Pick a Date
  • SLEEP HISTORY

  • WEEKDAY SLEEP SCHEDULE

     

  • WEEKEND/VACATION SLEEP SCHEDULE

  • NAP SCHEDULE

  • If child naps, write in usual nap time(s) from start to finish:

  • GENERAL SLEEP

  • CURRENT SLEEP SYMPTOMS

  • CURRENT DAYTIME SYMPTOMS

  • PREGNANCY/DELIVERY

  • MEDICAL AND PSYCHIATRIC HISTORY

  • PAST MEDICAL  HISTORY

  • PAST PSYCHIATRIC/PSYCHOLOGICAL HISTORY

  • CURRENT MEDICAL HISTORY

  •  
  • LONG TERM MEDICAL PROBLEMS

  • SURGERIES/HOSPITALIZATIONS

  • HEALTH HABITS

  • SCHOOL PERFORMANCE

  • FAMILY’S INFORMATION

  • MOTHER

  • FATHER

  •  
  • FAMILY SLEEP HISTORY

  • If yes, mark the disorder

  • REFERRAL

    Who asked that your child be seen by a sleep specialist?
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  • Should be Empty:
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