Bedtime Problems

Does your child have any problems going to bed?* Does your child have any problems going to bed?* Yes No

Does your child have any problems falling asleep?* Does your child have any problems falling asleep?* Yes No

Excessive Daytime Sleepiness

Does your child seem overtired or sleepy a lot during the day?* Does your child seem overtired or sleepy a lot during the day?* Yes No

Does he/she still take naps?* Does he/she still take naps?* Yes No

Awakenings During the Night

Does your child wake up a lot at night?* Does your child wake up a lot at night?* Yes No

Regularity and Duration of Sleep

Does your child have a regular bedtime and wake time?* Does your child have a regular bedtime and wake time?* Yes No

What time is bed time?*

What time is wake time?*

Snoring

Does your child snore a lot or have difficulty breathing at night?* Does your child snore a lot or have difficulty breathing at night?* Yes No

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