Child’s Sleep Habits Questionnaire

The following statements are about your child’s sleep habits and possible difficulties with sleep.

Think about the past week in your child’s life when answering the questions. If last week was an unusual week for a specific reason (such as your child had an ear infection and did not sleep well, or the TV set was broken) choose the most recent typical week.

Answer USUALLY if something occurs 5 or more times.
Answer SOMETIMES if it occurs 2-4 times in a week.
Answer RARELY if something occurs never or 1 time during a week.
Indicate whether or not the sleep habit is a problem by checking the box “Yes”,” No”, or “not applicable (N/A)”.

Patient's Name

First Name

Last Name

Date

YYYY

Write in the chid's usual bedtime.

Write in the child's usual wake up time.

Write in the child's usual amount of sleep each night (with no naps), please include the hours and minutes.

Child goes to bed at the same time each night?

Child falls asleep alone in their own bed?

Child falls asleep within 20 minutes after going to bed?

Child sleeps about the right amount each day?

Child sleeps about the same amount each day?

Child wakes up by him/herself?

Child has appeared very sleepy or fallen asleep during the following (check all that apply):

Watching T.V.

Riding in the car

Child falls asleep in parent's or sibling's bed.

Child struggles at bedtime (cries, refuses to stay in bed, etc.)

Child needs parent in the room to fall asleep?

Child is afraid of sleeping alone?

Child sleeps too little?

Child is afraid of sleeping in the dark?

Child is afraid of sleeping away from home? (visiting relatives, vacations)

Child moves to someone else's bed during the night? (parent, siblings, etc.)

Child awakens once during the night?

Child awakens more than once during the night?

Child talks during sleep?

Child is restless and moves a lot during sleep?

Child sleep walks during the night?

Write the number of hours and minutes a night they are sleep walking.

Child wets the bed at night

Child grinds teeth during sleep? (Your dentist may have told you this)

Child awakens alarmed or by a frightening dream?

Child awakens during the night and is screaming, sweating, and or inconsolable?

Child snores loudly?

Child seems to stop breathing during sleep?

Child snorts and/or gasps during sleep?

Child wakes up in a negative mood?

Do adults or siblings wake up child?

Child has difficulty getting out of bed in the morning?

Child seems tired in the morning?

Child Intake Form

Child’s Sleep Habits Questionnaire

HIPPA Private Practices Form