Sleep Questionnaire for Children (aged 4-16yrs)

General Details

Full Name of Child *

Phone *

Please provide parent/guardian number if number is not applicable

Email *

Please provide parent/guardian email if email is not applicable

Section 1: General Sleep Patterns

What time does your child usually go to bed on school nights?

Provide the typical bedtime, including any variations (Monday - Friday)

What time does your child usually wake up on school mornings?

State the usual wake-up time, including alarms or natural waking.

What time does your child usually go to bed on weekends?

Indicate if there is a significant difference from school nights.

What time does your child usually wake up on weekends?

Mention whether wake up is later or at the same time as weekdays.

How long does it take your child to fall asleep after going to bed?

Estimate the average time it takes to fall asleep if known.

Does your child wake up during the night? If yes, how often and for how long?

Describe the frequency and duration of night-time awakenings.

Does your child nap during the day?

If yes, how long and at what time?

If your child has insomnia, how does it impact their life?

Please include how it impacts home life, relationships with friends and family and the impact it has upon school.

Section 2: Sleep Environment and Habits

Does your child sleep in their own bed or share a bed?

Indicate whether sleep is alone or with a sibling/parent.

Does your child have a regular bedtime routine? (e.g., reading, bath, quiet time)

List any activities that help them prepare for sleep.

Does your child use electronic devices (TV, tablet, phone) before bedtime?

Specify the duration and type of screen use before bed.

How would you describe your child's bedroom environment? (e.g., dark, quiet, cool, comfortable)

Include any factors that impact sleep quality.

Does your child complain of discomfort (e.g., too hot/cold, noise disturbances) during sleep?

Mention any environmental issues affecting sleep.

Section 3: Sleep-Related Issues

Does your child experience difficulty falling and/or staying asleep?

Please explain the above in more detail

Describe how often they struggle to fall asleep and/or stay asleep.

Does your child experience nightmares or night terrors?

Provide detail of the above

Describe how often they have bad dreams or night terrors.

Does your child snore or have breathing difficulties during sleep?

Mention if they snore loudly, gasp, or pause breathing. If yes to either of these things please see below and complete the questionnaire below.

Please complete the British Snoring & Sleep Apnoea Association Questionnaire by following the provided link. Once you receive your results, copy and paste the section that states your score (e.g., Your score is 3/8. You could be at risk for Obstructive Sleep Apnoea (OSA)) into the designated area.

Please use the link below complete the questionaire.

Provide Score Here

Does your child sleepwalk or experience restless movements during sleep?

Indicate any known instances of sleepwalking or excessive movement.

Please complete this sleep diary as part of the NICE guidelines, which require us to assess sleep quality and duration. You can download the sleep diary from the following website: Sleep Foundation Diary. Once completed, please up-load the sleep diary below.

Please use the link below to download diary.

Use this area to upload your sleep diary

Does your child experience excessive daytime sleepiness?

Describe how often they seem tired during the day.

Does your child struggle to wake up in the morning and feel refreshed?

State whether they wake up feeling well-rested or fatigued.

Section 4: Past and current medical history

Does your child have a history of sleep problems or previous treatments?

Please describe any past or current sleep difficulties and any treatments they have received.

Does your child have any medical conditions?

Please include any medical conditions your child has been diagnosed with (this also includes chronic pain)

Is your child neurodivergent and/or living with mental health conditions?

Please tell us if your child is neurodivergent (ADHD, ASC, or both) or is awaiting a diagnosis. Please also include if your child has been diagnosed with any mental health conditions.

Section 5: Prescribed medication

Is your child currently taking any medications?

Please list any medications your child is taking, including those prescribed or over-the-counter. Please include frequency and dose of medication.

Have you noticed any changes in your child's sleep since starting any medication?

Some medications, such as corticosteroids, SSRIs, and beta-blockers, can cause sleep difficulties. Please mention any concerns related to your child’s sleep and their medication.

Section 6: Substance use

Does your child consume any substances that may affect their sleep?

This includes caffeine (e.g., tea, coffee, energy drinks), nicotine, or any other substances. Please provide details if applicable.

Section 7: Additional Information

Is there anything else you feel we should know?

Please use this space for anything you feel is relevant.