| Sleep History items (0 = Never 1=Rarely 2=Sometimes 3=Frequently 4=Always) |
| • Wakes up screaming during the night |
• Would stay in bed until gotten up |
| • Screams during the second half of the night |
• Is sleepy during the day |
| • Throws tantrums at bedtime |
• Goes to bed at different times |
| • Sleeps better in places other than his/her bed |
• Walks in sleep |
| • Gets less than 6 hours sleep in a 24 hour period |
• Rocks body, bangs head, or rocks head in sleep |
| • Talks in sleep without knowing it |
• Snores |
| • Sleeps more than other children his/her age |
• Resists going to bed at night |
| • Is sluggish or irritable when awakened |
• Sleeps less than children his/her age |
| • Has trouble falling asleep |
• Has frequent let movements while asleep |
| • Takes frequent naps during the day |
• Sleeps in a family bed |
| • Stops breathing during sleep |
• Has nightmares |
| • Complains of the room or bed being uncomfortable |
• Wakes up screaming approximately 2 hours after going to sleep |
| • Sleeps longer or shorter periods on the weekends versus the weekdays |
• Needs a stuffed animal, toy, blanket, pacifier, night light to fall asleep |
| • Engages in violent behavior while asleep (hits, kicks, punches) |
• Expresses fear about going to sleep or is afraid to fall asleep |
| • Complains of jaw pain during the day or grinds teeth at night |
• Takes naps without being told or at an age when naps are not normal |
| How many hours does your child sleep per night? |
| How many hours does your child nap during the day? |
| How many hours does you child sleep in 24 hours? |
