Interview Team: INTERVIEW QUESTIONNAIRE: Teenage Sleep Clinic
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- Georgia Osborne
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1 Interview Team: Date: INTERVIEW QUESTIONNAIRE: Teenage Sleep Clinic The aim of this questionnaire is to learn more about you, your habits, and your sleep. This will help us to understand about the problems with your sleep. Please fill in as much of the questionnaire as you can. Your sleep counsellor will answer any questions and can help you with the form. If anything is not clear, please ask. 1. Introduction 1.1 Your details Name: D.O.B. Address: Tel: Mobile: School/College/Place of Work: Address: Tel: Times Attending/ Working (give example, if working shifts): Mon Tues Wed Thurs Fri Sat Sun 1.2 Family Information Parent(s)/Guardian(s): Age(s): Occupation(s)/Shift Work: Sibling(s): Age(s): Other family information: 1.3a Professional Contact Doctor: Address: Tel: 1.3b Other Professional(s) (e.g. Guidance Teacher, Ed Psych, Social Worker, CPN, Befriender) Name: Address: Profession: Tel: Name: Address: Profession: Tel: 1
2 2. Living and Sleeping Arrangements 2.1 What type of home do you live in? e.g. 2 nd floor flat, terrace house, etc. 2.2 Have you ever had problems with noise from outside? E.g. neighbours, road, train. Please describe 2.3a Do you share a room? 2.3b If yes, does the person you share with do anything that keeps you awake, or wakes you during the night? 2.4 Do you share a bed with anyone else? 2.5 Please describe or draw your bedroom. Useful items to include: Bed (single/double/bunk bed), furniture (wardrobe, drawers, desk), technology (TV, games console, music player/speakers), lighting (lamps, blinds, curtains), other (pets, clock, etc.) 2.6 How much time do you spend in your room? What do you do there? Reading, school work, listening to music, watching TV/films etc. 2
3 2.7a How much time per day do you spend on a PC/tablet/phone? What do you do spend that time doing? (Watching videos/steaming, messenger apps/chat rooms, blogs/discussion sites etc.) 2.7b Do you spend time on Social Media? How much time per day? 2.7c Do you play games online (games console or on phone/tablet etc.)? How much time per day, and what time of the day? 2.7d How long before going to bed do you switch off your PC/tablet/phone? 2.7e Do you use your phone as an alarm? If so, does it light up or make a noise with notifications through the night? 2.7f Is there anything about any of the above that you think disturbs your sleep? 3. General Health If you feel a question in this section is not relevant, please mark it N/A. 3.1a Have you been diagnosed with any medical conditions, such as epilepsy, asthma, eczema, etc.? If yes, please describe: 3.1b Are you on any medication at the moment? If yes, please describe: 3.1c If you have epilepsy: What form is it? Is it controlled? How often and when do you have seizures? 3.2a Do you consider yourself as someone with a learning difficulty or disability? If yes, please describe: 3.2b Has anyone else suggested this? 3.2c Do you receive any extra support in school, college or work? 3
4 3.3 Do you have any physical disabilities? If yes, please describe: (e.g. Do you need support to move around? Do you need a particular or varied positioning for eating, sleeping etc.?) 3.4a Do you consider yourself as someone with a visual or hearing difficulty? If yes, please describe: 3.5a Do you often find you have problems making yourself understood? If yes, are you able to describe what these problems are? 3.5b Do you feel you often have difficulties understanding what someone else is saying? If so, can you give an example? 3.6 Do you sometimes/often need help with looking after yourself (toileting/showering/ dressing etc.)? If yes, please describe: 3.7 Do you have any other additional support needs? If yes, please describe: 3.8a Do you smoke? If so, how often? 3.8b Do you drink alcohol or take any non-prescription or recreational drugs? If so, how often? 3.9a How would you describe your mental health? Is there anything about your current or past mental health that you would like to share? 3.9b Do you often feel stressed, anxious or depressed? If so, are you able to describe how you feel? 3.9c Are you receiving any support for your mental health? E.g. counselling, medication etc. 4
5 4. Nutrition 4.1a Do you have regular mealtimes? If yes, how many and at what times? 4.1b What would you typically eat? 4.1c If no, please describe 4.2 Do you have snacks? If so, how often, and what do you eat? 4.3a What do you like to drink? 4.3b How often do you have drinks: During the day? During the evening? At night time when in bed? 4.4a Do you have any problems eating or drinking? If yes, please describe: 4.4b Are you receiving any support with eating? E.g. counselling, therapy, medical intervention 5
6 5. Routines In this section we want to get a brief idea of a typical weekday and weekend day for you. We will cover aspects of your routine in more detail in the next section. 5.1 Please describe your routine from the time you wake through to going to sleep (Remember to cover waking, meals and snacks, bath/shower, preparing for bed, time you go to bed) Time Weekday Time Weekend 6
7 5.2a Do you have any regular clubs, lessons or other activities you regularly attend? If yes, which days and at what times? 6. Sleep History 6.1 What do you consider to be the main problem and when did it start (e.g. since birth/early childhood, after an illness, death of a relative or friend)? 6.2 Have you ever visited the doctor or any other professionals to discuss your sleep problem? If yes, please describe what was offered and what worked/did not work: 6.3 Have you tried any strategies to improve your sleep problem? If yes, please describe: 6.4a Do you fall asleep on your own? If no, please describe how you fall asleep: 6.4b Have you always been able to sleep on you own, or did you need a parent etc. with you when you were younger? 6.5 Do you ever fall asleep somewhere other than your own bed? If yes, please describe where: 7
8 6.6a Do you have any of the following movements or behaviours during sleep? Sleep Walking Snoring Sleep Talking Wake gasping for breath Wake Screaming Stop Breathing Nightmares Excessive movement Grinding Teeth Unusual sleeping position Wetting Bed Other (please describe) 6.7a Do you wake up during the night? If yes, how often, how long for, and at what times? 6.7b Do you try and get back to sleep? If yes, what do you get back to sleep? If no, what do you do once you are awake? 6.8a Do you have to be woken in the morning by someone, an alarm, or do you wake up naturally? 6.8b If you have to be woken, who wakes you and at what time? Are you easy to wake? 6.8c What time would you get up if you were left to wake up naturally? Do you tend to sleep later at the weekend/holidays/days off? 6.9a Do you ever feel very sleepy during the day? If yes, please describe: 6.10a Do you ever have naps during the day? If yes, how often? 6.10b What time(s) during the day and for how long? 6.10c Where would you take these naps (sofa, bus, bed, school etc)? 8
9 6.11 Do you sleep away from home regularly (e.g. wider family, friends, holiday home)? If so, where, and how do you sleep there? 6.12 How many hours sleep do you think you get in a 24hr period? Does it vary at the weekend? 7. General Well-being 7.1 Is there anything that worries you about going to bed or sleeping? If yes, what is it? 7.2 How do you feel when you wake in the morning? 7.3 How is your mood in general (happy, outgoing, angry, sad etc.)? 7.4a Do you feel your sleep problem has affected relationships with your family? If yes, how has it? 7.5a Does your sleep problem affect your social life? If yes, how does it? 8. Long Term Aims 8.1 How would you like things to change? 8.2 Do you have any concerns about the programme? If so, what are they? 9
10 8.3 Is there any information that we have not covered which you think is important for us to know? 8.4 Do you have any questions about our clinic? 9. The Next Steps of The Programme Thank you for completing this questionnaire. Your Sleep Counselling Programme will take place over a series of appointments. They will be as follows: Appointment Type of Appointment Who should come 2 Home visit You and parent(s)/guardian(s) 3 Sleep Programme You and parent(s)/guardian(s) 4 Ongoing Support You 5 Ongoing Support You 6 Ongoing Support You 7 Review You and parent(s)/guardian(s) Your sleep counsellor will now explain sleep diaries, why it is important to keep them and how to fill them in. They should also set a date and time for your next appointment. In order for the programme to work well, it is important you try each day and evening to make the changes that the sleep counsellor suggests. You may try some things that don t work. Don t worry; discuss them with your sleep counsellor to see if they can be changed. 10
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