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.
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
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
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.
WEEKDAY SLEEP SCHEDULE
WEEKEND AND VACATION SLEEP SCHEDULE
Complete this section only if the child takes naps.
What are the child’s usual nap times?
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