Bedtime Problems

Parent: Does your child have any problems at bedtime?* Parent: Does your child have any problems at bedtime?* Yes No

Child: Do you have any problems going to bed?* Child: Do you have any problems going to bed?* Yes No

Excessive Daytime Sleepiness

Parent: Does your child have difficulty waking in the morning, seem sleepy during the day or take naps??* Parent: Does your child have difficulty waking in the morning, seem sleepy during the day or take naps??* Yes No

Child: Do you feel sleep a lot?* Child: Do you feel sleep a lot?* Yes No

Awakenings During the Night

Parent: Does your child seem to wake up a lot at night?* Parent: Does your child seem to wake up a lot at night?* Yes No

Parent: Any sleepwalking or nightmares?* Parent: Any sleepwalking or nightmares?* Yes No

Child: Do you have trouble getting back to sleep?* Child: Do you have trouble getting back to sleep?* Yes No

Regularity and Duration of Sleep

Parent: What time does your child go to bed and get up on school days?*

Parent: Weekends?*

Parent: Do you think he/she is getting enough sleep?* Parent: Do you think he/she is getting enough sleep?* Yes No

Snoring

Does your child have loud or nightly snoring or any breathing difficulties at night?* Does your child have loud or nightly snoring or any breathing difficulties at night?* Yes No

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