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.

White/Caucasian Black/African-American Asian American Native-American Hispanic-Latino Multi-racial Other

WEEKDAY SLEEP SCHEDULE

WEEKEND/VACATION SLEEP SCHEDULE

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

own room in own bed (alone) parent's room in own bed parent's room in parent's bed sibling’s room in own bed sibling's room in sibling's bed

own room in own bed (alone) parent's room in own bed parent's room in parent's bed sibling's room in own bed sibling's room in sibling's bed

Mother Father Both Parents Self Others

CURRENT SLEEP SYMPTOMS

Never (does not happen) Not often (less than 1 night/day a week) Sometimes (1 to 2 nights/days a week) Often (3 to 5 nights/days a week) Always (6 to 7 nights/days a week) Do not know

CURRENT DAYTIME SYMPTOMS

Never (does not happen) Not often (less than 1 night/day a week) Sometimes (1 to 2 nights/days a week) Often (3 to 5 nights/days a week) Always (6 to 7 nights/days a week) Do not know

Term Pre-Term Post-Term

1st 2nd 3rd 4th 5th 6th 7th

PAST MEDICAL HISTORY

PAST PSYCHIATRIC/PSYCHOLOGICAL HISTORY

CURRENT MEDICAL HISTORY

	Medicine Name	Dose	How Often
Medicine 1
Medicine 2
Medicine 3
Medicine 4

LONG TERM MEDICAL PROBLEMS

SURGERIES/HOSPITALIZATIONS

Excellent Good Average Poor Failing

Single Divorced Separated Married Widowed Remarried

Unemployed Part-Time Full-Time

Single Divorced Separated Married Widowed Remarried

Unemployed Part-Time Full-Time

	Name	Relationship	Age
Person 1
Person 2
Person 3
Person 4
Person 5

FAMILY SLEEP HISTORY

If yes, mark the disorder

Mother Father Brother/Sister Grandparent

Pediatrician/Family Physician Child's Parent or Guardian Surgical Specialist (e.g. ENT) Pediatric Specialist (e.g., allergist, neurologist, pulmonologist) Mental Health Specialist (e.g., psychiatrist, psychologist, social worker) School teacher, nurse, counselor Child himself/herself Other

Child Sleep Evaluation Questionnaire

CHILD’S INFORMATION

SLEEP HISTORY

PREGNANCY/DELIVERY

MEDICAL AND PSYCHIATRIC HISTORY

SCHOOL PERFORMANCE

FAMILY’S INFORMATION

REFERRAL