Pediatric Sleep Evaluation Questionnaire

Accredited by the American Academy of Sleep Medicine

Please complete this questionnaire by choosing or filling in the answer that best fits your child.

If the child cannot directly answer a question, please provide an estimate based on your own observations.
For older children and teens, it might be best to fill out the questionnaire together.
These questions span children of many ages; if a question appears inappropriate for your child’s age, please just ignore it.
We know that the parenting role can comprise many different people. Please assume that the word “parent” includes foster parents, legal guardians, grandparents and other family members, and anyone else in a parenting role.

GENERAL INFORMATION

Child’s Legal First & Last Name

Child’s gender

Male Female Non-Binary

Child’s Date of Birth

Age

Weight

Height

INSURANCE CARD FRONT AND BACK ARE REQUIRED. Please upload a copy of your current insurance cards. Reporting any secondary insurance is required.

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Please upload a file

PHOTO ID FRONT AND BACK ARE REQUIRED. Please upload a copy of your current photo ID.

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Please upload a file

THE EPWORTH SLEEPINESS SCALE

How likely is the child to doze off or fall asleep in the following situations? Even if the child has not done some of these things recently, give your best estimate for each situation, using the scale below. If the child is too young to respond directly, please choose a response based on what you’ve observed. When you’ve completed the table, add all the scores and fill in the total. t

0: Would NEVER doze

1: SLIGHT chance of dozing

2: MODERATE chance of dozing

3: HIGH chance of dozing

Chance of dozing (0–3)

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g., a theater or a classroom)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon if they are able

Sitting and talking to someone

Sitting quietly after lunch

Doing homework or taking a test

TOTAL SCORE

SLEEP CONCERNS

What are your major concerns about the child’s sleep?

Has the child previously had a sleep study?

Yes No

If Yes, when and where?

SCHOOL PERFORMANCE

Complete this section only if the child is school-age.

Child’s grade

Has the child ever repeated a grade?

No Yes

Is the child homeschooled?

No Yes

Does the child receive any special education services?

No Yes

If Yes, please describe.

Has the child ever missed or been late to school due to sleep issues?

No Yes

If Yes, how often?

Has the child ever fallen asleep in school?

No Yes

If Yes, how often?

How are the child’s grades this year?

Excellent Good Average Poor Failing

Does the child have any difficulties with school performance (e.g., paying attention, concentrating) or any behavioral issues (e.g., hyperactivity)?

No Yes

If Yes, please tell us about them.

Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician or a psychologist, or any concerns the child’s teachers have expressed.

SLEEP HISTORY

WEEKDAY SLEEP SCHEDULE

What is the child’s usual bedtime on weekday nights?

What is the child’s usual waking time on weekday mornings?

How long does it usually take the child to fall asleep on weekdays?

Add the child’s daytime and nighttime sleep hours. How much does the child sleep during a typical 24-hour period on weekdays?

WEEKEND AND VACATION SLEEP SCHEDULE

What is the child’s usual bedtime on weekend/vacation nights?

What is the child’s usual waking time on weekend/vacation mornings?

How long does it take the child to fall asleep on weekend/vacation nights?

Add the child’s daytime and nighttime sleep hours. How much does the child sleep during a typical 24-hour period on weekends and vacations?

NAP SCHEDULE

Complete this section only if the child takes naps.

How many days each week does the child take a nap?

0 1 2 3 4 5 6 7

What are the child’s usual nap times?

a.m. p.m.

From what you’ve observed, are the child’s naps refreshing?

Yes No

GENERAL SLEEP

Does the child currently take, or have they taken in the past, any prescribed or over-the-counter medications (including melatonin) for sleep?

Yes No

If Yes, which medications, what dose, and for how long?

If Yes, was the medication effective?

Yes No

Does the child have difficulty falling asleep?

Yes No

If Yes, for how long?

Does the child awaken during the night?

Yes No

If Yes, how many times?

After waking at night, does the child have difficulty falling back to sleep?

Yes No

If Yes, for how long?

Is the child difficult to awaken in the morning?

Yes No

If Yes, do you think this is a problem?

Yes No

Does the child resist going to bed?

Yes No

If Yes, do you think this is a problem?

Yes No

Does the child have a regular bedtime routine?

Yes No

Does the child watch TV or use electronic devices (computer, tablets, phones, etc.) before bed?

Yes No

If Yes, how close to bedtime?

Does the child have their own bedroom?

Yes No

If no, shares with?

Is the child’s sleeping area cool, dark, and quiet?

Yes No

Is the child bothered by outside lights, noise, people, and/or animals when trying to sleep?

Yes No

Who usually puts the child to bed?

Mother Father Both Parents Child does it themselves Other

If other, please specify.

Is a parent present when the child falls asleep?

Yes No

Does the child fall asleep in their own bed?

Yes No

Does the child sleep most of the night in their own bed?

Yes No

When the child is awake at night, do they complain of their mind racing or being worried or scared?

Yes No

In which of the following positions does the child sleep? Check all that apply:

On their back

On their sides

On their stomach

With their neck hyperextended

Elevated on pillows

CURRENT SLEEP SYMPTOMS

Use the scale below to give your best estimate for each situation. If the child is too young to respond directly, please choose a response based on what you’ve observed.

a: Never (does not happen)

b: Not often (less than 1 night/day per week)

c: Sometimes (1 to 2 nights/days per week)

d: Often (3 to 5 nights/days per week)

e: Almost always (6 to 7 nights/days per week)

f: I do not know

Does the child ever:

1. Snore

a b c d e f

2. Stop breathing during sleep

a b c d e f

3. Choke or gasp at night

a b c d e f

4. Breathe mainly through their mouth at night or have noisy breathing

a b c d e f

5. Have significant nasal congestion at night

a b c d e f

6. Have known reflux at night or awaken with a bad taste in their mouth as if acid has come up

a b c d e f

7. Appear restless during sleep; toss and turn when asleep

a b c d e f

8. Sweat when sleeping

a b c d e f

9. Complain of a headache upon awakening

a b c d e f

10. Grind their teeth

a b c d e f

11. Wet the bed during sleep

a b c d e f

12. Kick their legs during sleep

a b c d e f

13. Report an uncomfortable feeling in their legs or a creepy-crawly feeling when they’re trying to go to sleep

a b c d e f

14. Sleepwalk

a b c d e f

15. Talk in their sleep

a b c d e f

16. Have night terrors (episodes of screaming, intense fear, and flailing while still asleep and is inconsolable afterward)

a b c d e f

17. Have frequent nightmares

a b c d e f

18. Feel weak or lose control of their muscles after exhibiting strong emotions

a b c d e f

19. Report being unable to move when falling asleep or upon waking

a b c d e f

20. Report seeing frightening visual images before falling asleep or upon waking

a b c d e f

MEDICAL AND PSYCHIATRIC HISTORY

PAST MEDICAL HISTORY

Does the child have a history of any of the following

Enlarged tonsils or adenoids?

Yes No

If Yes, age of diagnosis:

Frequent colds or flus?

Yes No

If Yes, age of diagnosis:

Frequent ear infections?

Yes No

If Yes, age of diagnosis:

Frequent strep throat infections?

Yes No

If Yes, age of diagnosis:

Difficulty swallowing?

Yes No

If Yes, age of diagnosis:

Trouble breathing through their nose?

Yes No

If Yes, age of diagnosis:

Sinus problems?

Yes No

If Yes, age of diagnosis:

Chronic bronchitis or cough?

Yes No

If Yes, age of diagnosis:

Allergies?

Yes No

If Yes, age of diagnosis:

If Yes, what is the child allergic to?

Asthma?

Yes No

If Yes, age of diagnosis:

Acid reflux (gastroesophageal reflux)?

Yes No

If Yes, age of diagnosis:

Poor or delayed growth?

Yes No

If Yes, age of diagnosis:

Excessive weight?

Yes No

If Yes, age of diagnosis:

Hearing problems?

Yes No

If Yes, age of diagnosis:

Speech problems?

Yes No

If Yes, age of diagnosis:

Vision problems?

Yes No

If Yes, age of diagnosis:

Seizures or epilepsy?

Yes No

If Yes, age of diagnosis:

Headaches?

Yes No

If Yes, age of diagnosis:

Cerebral palsy?

Yes No

If Yes, age of diagnosis:

Heart disease?

Yes No

If Yes, age of diagnosis:

High blood pressure?

Yes No

If Yes, age of diagnosis:

Sickle cell disease?

Yes No

If Yes, age of diagnosis:

Genetic disease?

Yes No

If Yes, age of diagnosis:

Chromosome problems (e.g., Down’s)?

Yes No

If Yes, age of diagnosis:

Skeleton problem (e.g., dwarfism)?

Yes No

If Yes, age of diagnosis:

Craniofacial disorder (e.g., Pierre-Robin)?

Yes No

If Yes, age of diagnosis:

Thyroid problems?

Yes No

If Yes, age of diagnosis:

Eczema (itchy skin)?

Yes No

If Yes, age of diagnosis:

Chronic pain?

Yes No

If Yes, age of diagnosis:

PAST PSYCHIATRIC/PSYCHOLOGICAL HISTORY

Does the child have a history of any of the following:

Hyperactivity or ADHD?

Yes No

If Yes, age of diagnosis:

Anxiety or panic attacks?

Yes No

If Yes, age of diagnosis:

Depression?

Yes No

If Yes, age of diagnosis:

Obsessive-compulsive disorder?

Yes No

If Yes, age of diagnosis:

History of suicidal thoughts or attempted suicide?

Yes No

If Yes, please describe.

Alcohol or other drug misuse?

Yes No

If Yes, please describe.

Autism?

Yes No

If Yes, age of diagnosis:

Developmental disability?

Yes No

If Yes, age of diagnosis:

Learning disability?

Yes No

If Yes, age of diagnosis:

Behavioral disorder?

Yes No

If Yes, age of diagnosis:

Psychiatric admission?

Yes No

If Yes, please describe.

MOTHER’S PREGNANCY AND DELIVERY HISTORY

Was the child’s delivery

To term Pre-term Post-term

Were either of the following required during the child’s birth?

A stay in the NICU

Yes No

Oxygen

Yes No

CURRENT MEDICAL HISTORY

Please list any medications the child currently takes

Add Medication

Is the child allergic to any medications?

Yes No

If Yes, please list them here.

SURGERIES AND HOSPITALIZATIONS

Has the child had their tonsils removed?

Yes No

If Yes, age of surgery.

Has the child had their adenoids removed?

Yes No

If Yes, age of surgery.

Has the child ever had ear tubes?

Yes No

If Yes, age of surgery.

Please list any additional hospitalizations or surgeries.

HEALTH HABITS

Does the child drink caffeinated beverages (e.g., Coke, Pepsi, Mountain Dew, iced tea, energy drinks)?

Yes No

If Yes, how many does the child drink?

How many hours per day of screen time (other than for school) does the child get?

How many hours per day of physical activity does the child get?

Are there any pets at home?

Yes No

Is the child exposed to tobacco at home?

Yes No

If Yes, how much tobacco is the child exposed to per day?

FAMILY INFORMATION

Parent / Guardian 1

Parent / Guardian 2

Relationship to patient

Other Persons Living in the Home

Add new row

FAMILY SLEEP HISTORY

Does anyone in the family have a sleep disorder?

Yes No

If Yes, mark the relevant disorder below, and indicate which family member has it:

Insomnia

Mother

Father

Brother/Sister

Grandparent

Snoring

Mother

Father

Brother/Sister

Grandparent

Sleep apnea

Mother

Father

Brother/Sister

Grandparent

Restless legs syndrome

Mother

Father

Brother/Sister

Grandparent

Sleepwalking or sleep terrors

Mother

Father

Brother/Sister

Grandparent

Sleep talking

Mother

Father

Brother/Sister

Grandparent

Narcolepsy

Mother

Father

Brother/Sister

Grandparent

Other

Mother

Father

Brother/Sister

Grandparent

If other, please specify.

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