Sleep Questionnaire Form

Patient Name:

Today's Date:

Is your child taking any medication?

Yes No

What is your childs usual bedtime?

How long does it take for him/her to fall asleep?

Does your child wake up at night?

Yes No

Is your child sleepy during the day?

Yes No

Does your child habitually nap?

Yes No

Does your child bang his/her head in their sleep?

Yes No

Does your child have leg pains?

Yes No

Does your child have nightmares?

Yes No

Does he/she scream in their sleep?

Yes No

Do they grind their teeth during sleep?

Yes No

Does your child sleepwalk?

Yes No

Does your child wet the bed?

Yes No

Does your child snore?

Yes No

Does your child mouth breathe?

Yes No

Does your child kick during sleep?

Yes No

Does your child sleep in unusual positions?

Yes No

Was your child born pre-maturely?

Yes No

Does your child sweat while asleep?

Yes No

Does your child have difficulty waking themselves up in the morning?

Yes No

Did your child have eczema, cradle cap, or other allergies at any time?

Yes No

Natural Delivery, C-Section or Other? (Please Select)

Natural

C-Section

Other