Pediatric Sleep Evaluation Questionnaire

Please correct the errors described below.

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

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

SCHOOL PERFORMANCE

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

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


WEEKEND AND VACATION SLEEP SCHEDULE


NAP SCHEDULE

Complete this section only if the child takes naps.

What are the child’s usual nap times?

GENERAL SLEEP

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:

MEDICAL AND PSYCHIATRIC HISTORY

PAST MEDICAL HISTORY

Does the child have a history of any of the following


PAST PSYCHIATRIC/PSYCHOLOGICAL HISTORY

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

MOTHER’S PREGNANCY AND DELIVERY HISTORY

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

CURRENT MEDICAL HISTORY

Please list any medications the child currently takes

Add Medication

SURGERIES AND HOSPITALIZATIONS

HEALTH HABITS

FAMILY INFORMATION

Other Persons Living in the Home

Add new row

FAMILY SLEEP HISTORY

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

Your information will be encrypted.

Loading...