☐ ☐ ☐ has trouble sleeping away from home Yes No N/A (visiting relatives, vacation). ☐ ☐ ☐ Child awakens during night screaming, sweating, Yes No N/A and inconsolable. ☐ ☐ ☐ awakens alarmed by a frightening dream. Yes No N/A Waking During the NIght ☐ ☐ ☐ Child awakens once during the night. Yes No N/A ☐ ☐ ☐ Child awakens more than once during the night. Yes No N/A ☐ ☐ ☐ Child returns to sleep without help after waking. Yes No N/A How many minutes does a typical night waking usually last? _________________________________________ Morning Waking ☐ ☐ ☐ Child wakes by him/herself. Yes No N/A ☐ ☐ ☐ Child wakes up with alarm clock. Yes No N/A ☐ ☐ ☐ Child wakes up in negative mood. Yes No N/A ☐ ☐ ☐ Adults or sibling wake up the child. Yes No N/A ☐ ☐ ☐ Child has difficulty getting out of bed in the morning. Yes No N/A ☐ ☐ ☐ Child takes a long time to become alert in the morning. Yes No N/A ☐ ☐ ☐ Child wakes up very early in the morning. Yes No N/A ☐ ☐ ☐ Child has a good appetite in the morning. Yes No N/A ☐ ☐ ☐ Child wakes up by self very early in the morning. Yes No N/A Daytime Sleepiness ☐ ☐ ☐ Child naps during the day. Yes No N/A ☐ ☐ ☐ Child suddenly falls asleep in the middle of active Yes No N/A behavior. ☐ ☐ ☐ Child seems tired. Yes No N/A During the past week, how sleep has your child Been in the following situations? Not Sleepy Very Sleepy Falls Asleep ☐ ☐ ☐ Playing alone ☐ ☐ ☐ Watching TV ☐ ☐ ☐ Riding in car ☐ ☐ ☐ Eating meals
has trouble sleeping away from home ☐ ☐ ☐ Yes No N/A (visiting relatives, vacation). Child awakens during night screaming, sweating, ☐ ☐ ☐ Yes No N/A and inconsolable. awakens alarmed by a frightening dream. ☐ ☐ ☐ Yes No N/A Waking During the NIght Child awakens once during the night. ☐ ☐ ☐ Yes No N/A Child awakens more than once during the night. ☐ ☐ ☐ Yes No N/A Child returns to sleep without help after waking. ☐ ☐ ☐ Yes No N/A How many minutes does a typical night waking usually last? _________________________________________ Morning Waking Child wakes by him/herself. ☐ ☐ ☐ Yes No N/A Child wakes up with alarm clock. ☐ ☐ ☐ Yes No N/A Child wakes up in negative mood. ☐ ☐ ☐ Yes No N/A Adults or sibling wake up the child. ☐ ☐ ☐ Yes No N/A Child has difficulty getting out of bed in the morning. ☐ ☐ ☐ Yes No N/A Child takes a long time to become alert in the morning. ☐ ☐ ☐ Yes No N/A Child wakes up very early in the morning. ☐ ☐ ☐ Yes No N/A Child has a good appetite in the morning. ☐ ☐ ☐ Yes No N/A Child wakes up by self very early in the morning. ☐ ☐ ☐ Yes No N/A Daytime Sleepiness Child naps during the day. ☐ ☐ ☐ Yes No N/A Child suddenly falls asleep in the middle of active ☐ ☐ ☐ Yes No N/A behavior. Child seems tired. ☐ ☐ ☐ Yes No N/A During the past week, how sleep has your child Been in the following situations? Not Sleepy Very Sleepy Falls Asleep Playing alone ☐ ☐ ☐ Watching TV ☐ ☐ ☐ Riding in car ☐ ☐ ☐ Eating meals ☐ ☐ ☐
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