Riley Sleep Evaluation Questionnaire
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1 Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like Not like Mark mistakes like Questionnaire filled out by: Place hospitcal sticker here. Relationship to patient: CHILD'S INFORMATION Child's Gender: Male Female Child's racial/ethnic background: (check all that apply) White/Caucasian Black/African American Hispanic-Latino Asian Native American Other What are your major concerns about your child's sleep? Please CHECK ALL that apply and PLACE A STAR NEXT TO YOUR MAIN CONCERN. Breathing problem during sleep (e.g. snoring) Feeling tired or sleepy during the day Restless movement during sleep Problems consistently getting enough sleep Problems falling or staying asleep Unusual episodes at night (e.g sleepwalking) Leg pain or discomfort before bed Other (please describe below) What have you tried to help your child's problem? Talking to my child's doctor about this Changing sleep habits (e.g. less caffeine) Sleep training approach (e.g Ferber method) Over the counter herbal medication Regular sleep routine Surgery for sleep apnea Prescription medication I have not tried anything Other: Page 1 of 6
2 Do you consider your child's sleep problem to be: No Problem Mild Moderate Severe Who asked that your child be seen by a sleep specialist? Pediatrician/Family physician Neurologist Psychiatrist, Psychologist or other mental health professional Ear, Nose, and Throat Doctor Other pediatric specialist (e.g., allergist, pulmonolgist) Other Child's Sleep History Where does your child usually sleep at night? Infant crib in a separate room In parents' bed Infant crib in parents' room Infant crib in room with sibling Other (please specify): In what position does your child sleep most of the time? On his/her belly On his/her side On his/her back How much time does your child spend sleeping during the NIGHT (between 7 in the evening and 7 in the morning)? hours minutes How much time does your child spend sleeping during the DAY (between 7 in the morning and 7 in the evening)? hours minutes What is the average number of times your child wakes during the night? How much time during the night does your child spend awake (from 10 in the evening to 6 in the morning)? hours minutes How long does it take to put your child to sleep in the evening? hours minutes How does your child fall asleep? While feeding Being held In bed near parent Being rocked In bed alone Other (please specify): What time does your child usually fall asleep for the night? : Page 2 of 6
3 The following statements are about your child's sleep habits and possible difficulties with sleep. Think about the past week in your child's life when answering these questions. If last week was unusual for a specific reason (such as your child was sick and did not sleep well), choose the most recent typical week. Answer USUALLY if something occurs 5 or more times in a week; answer SOMETIMES if it occurs 2-4 times in a week; answer RARELY if something occurs never or 1 time during a week. 1. Child goes to sleep at the same time at night 2. Child struggles at bedtime (cries, refuses to stay in bed, etc.) 3. Child sleeps too little 4. Child sleeps the right amount 5. Child sleeps about the same amount each day 6. Child is restless and moves a lot during sleep 7. Child grinds teeth during sleep (dentist may have told you this) USUALLY (5-7 nights) SOMETIMES (2-4 nights) RARELY (0-1 nights) 8. Child snores loudly 9. Child seems to stop breathing during sleep 10. Child snorts and/or gasps during sleep 11. Child awakens during the night screaming, sweating, and inconsolable 12. Child awakes once during the night 13. Child awakes more than once during the night 14. Child wakes up by him/herself 15. Child wakes up in negative mood 16. Adults or siblings wake up child 17. Child takes a long time to become alert in the morning 18. Child seems tired 19. Child shows repetitive actions such as rocking or headbanging while falling asleep? Page 3 of 6
4 Family's Information Mother Father Age: Age: Single Married Single Married Marital Status: Divorced Widowed Marital Status: Divorced Widowed Separated Remarried Separated Remarried Less than High School Less than High School Highest Level of Education: High School or GED Diploma Some College Highest Level of Education: High School or GED Diploma Some College Bachelor's degree or higher Bachelor's degree or higher Occupation: Occupation: Birth order of the child being seen today: Oldest Middle Youngest Smoking Does anybody who lives in the home smoke cigarettes? No Yes, Inside the Home Yes, Outside only Are you interested in learning more about ways to help you or someone else quit smoking? No Yes Not Sure Medications Please list any medications your child currently takes: Medicine Dose How often? Page 4 of 6
5 Child's Medical History Please check all conditions your child has now or has had in the past Past Now Past Now Trouble breathing through his/her nose Chronic bronchitis or cough Allergies Asthma Feeding problems Frequent strep throat infections Infant apnea Acid reflux (gastroesophageal reflux) Poor or delayed growth Excessive weight Hearing problems Speech problems Vision problems Seizures/Epilepsy Morning headaches Sickle cell disease Cranofacialdisorder (e.g., Pierre-Robin) Thyroid problems Eczema (itchy skin) Chronic or persistent pain Trauma (e.g. abused, witnessed crime) Chromosome problem (e.g., Down's) Skeleton problem (e.g., dwarfism) Autism Developmental delay Hyperactivity/ADHD Anxiety or worries Behavioral disorder Heart disease High blood pressure Cerebral palsy Please list any additional medical, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician/psychologist. Pregnancy/Delivery Pregnancy Delivery Normal Complications Term Pre-term - How many weeks? Child's Birth Weight lb oz Page 5 of 6
6 Surgeries/Hospitalizations Riley Sleep Evaluation Questionnaire Has your child ever had his/her tonsils removed? Reason for surgery: No Yes Age at Surgery Has your child ever had his/her adenoids removed? No Yes Age at Surgery Reason for surgery: Has your child ever had ear tubes? No Yes Age at Surgery Reason for surgery: Family Sleep History Does anyone in the family have a sleep disorder? No Yes If yes, mark the disorder(s): Insomnia Snoring Sleep apnea Restless legs syndrome Sleepwalking/sleep terrors Narcolepsy Infant Apnea SIDS Other: THANK YOU for your time in completing this questionnaire. If there is any other know about your child or family, please write it in the space below. information you would like us to Page 6 of 6
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like t like
Sleep Evaluation Questionnaire
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