Does my child have a sleeping disorder?

1. Age of child

1
2
3
4-5
6-7
8-10
10-12
Over 12
Please make a selection.

2. How long has sleep been an issue for this child?

1 month or less
2-4 months
4-6 months
6 months to 1 year
Longer than a year
Please make a selection.

3. How frequently is getting your child to sleep a problem?

Every night
More than three times a week
Less than three times a week
Please make a selection.

4. Have there been any family changes, bereavements, traumas in the past year?

5. Where does your child most regularly sleep?

Alone in his/her bedroom
In a bedroom with one or more siblings
In a separate bed in the parents' bedroom
In bed with the parents
Starts off in own bed and moves to parents' bed
Please make a selection.

6. Would you describe your main sleep difficulty as:

Getting your child to sleep
Getting your child to stay asleep
Getting your child to sleep in his/her own bed
Getting your child to stay in his/her own bed
Please make a selection.

7. What time do you start the bedtime routine?

6-7pm
7-8pm
8-9pm
9-10pm
10pm or later
Please make a selection.

8. What time does your child usually fall asleep?

6-7pm
7-8pm
8-9pm
9-10pm
10-11pm
11pm or later
Please make a selection.

9. How long does the normal bedtime routine take (The average time between first getting the child in to bed and when the child finally falls asleep)

10-20 mins
20-40 mins
40mins to 1 hour
1-2 hours
2-3 hours
more than 3 hours
Please make a selection.

10. How many hours of crying, tantrums or general distress does bedtime regularly include?

10-20 mins
20-40 mins
40mins to 1 hour
1-2 hours
2-3 hours
more than 3 hours
Please make a selection.

11. How would you rate the frustration levels of the parents during bedtimes on a scale of 1-10?

1 2 3 4 5 6 7 8 9 10 Select

12. How long does your child sleep during the first period of sleep (from first falling asleep until the first time they wake up in the night?

Less than an hour
1-3 hours
3-5 hours
5-7 hours
7-9 hours
more than 9 hours
Please make a selection.

13. How many hours does your child regularly get in total during the night?

less than 3 hours
3-5 hours
5-7 hours
7-9 hours
9-11 hours
more than 11 hours
Please make a selection.

14. Does your child regularly (once a week or more) have any kind of nightmares?

yes
no
Please make a selection.

15. Does your child have any other sleep disturbance such as:

Sleepwalking
Significant Sleepwalking
Night terrors
Other - Please state

16. Does your child have a nap during the day and if so for how long?

Less than 20 mins
20-30 mins
30mins-1 hour
1 hour to 1 hour and a half
1 hour and a half to 2 hours
More than 2 hours
More than 3 hours
Please make a selection.

17. How would you describe your child during the day?

Really exhausted and grumpy
A little tired
Not at all tired
Full of energy
Wired and over-active
Please make a selection.

18. How badly is the parent's sleep being disturbed?

Very badly
Significantly
A little
Not at all
Please make a selection.

19. How do you feel about your child's sleeping pattern (please tick all that apply)

Relaxed
Anxious
Angry
Worried
Frustrated
Desperate
Other - Please state

20. What do you think underlies your child's difficulty (please tick all that apply)?

Anxiety
Stubborness
Wish to stay up with parents
Not tired at bedtime
Haven't yet learnt how to sleep alone
Other - Please state

21. Please give a brief statement (up to 100 words) of any other information you feel is relevant to your child's sleep difficulties

Please type here...