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Mental Health – Insomnia Assessment
Michael
2024-09-17T11:21:19-05:00
INSOMNIA ASSESSMENT
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*
" indicates required fields
Please answer questions 1 – 28 about your child’s sleep during the PAST 4 WEEKS.
1. While sleeping, does your child snore?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
2. While sleeping, does your child have “heavy” or loud breathing?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
3. While sleeping, does your child have trouble breathing, or struggle to breathe?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
4. Does your child snort and/or gasp during sleep?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
5. Have you seen your child stop breathing during the night?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
6. Does your child tend to breathe through the mouth during the day?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
7. Does your child have a dry mouth or sore throat on waking up in the morning?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
8. Does your child go to bed at the same time at night?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
9. Does your child fall asleep alone in his/her own bed?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
10. Does your child fall asleep within 20 minutes after going to bed?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
11. Does your child sleep the right amount?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
12. Does your child sleep the same amount each day?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
13. Does your child fall asleep in parent’s or sibling’s bed?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
14. Does your child struggle at bedtime (cries, refuses to stay in bed, etc.)?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
15. Does your child need a parent in the room to fall asleep?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
16. Is your child afraid of sleeping alone?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
17. Is your child afraid of sleeping in the dark?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
18. Does your child have trouble sleeping away from home (visiting relatives, vacation)?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
19. Does your child move to someone else’s bed during the night (parent, sibling, etc.)?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
20. Does your child awaken once during the night?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
21. Does your child awaken more than once during the night?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
22. Does your child talk during sleep?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
23. Is your child restless and move a lot during sleep?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
24. Does your child sleepwalk during the night?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
25. Does your child wet the bed at night?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
26. Does your child grind his/her teeth during sleep? (your dentist may have told you this)
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
27. Does your child awaken alarmed by a frightening dream?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
28. Does your child awaken during the night screaming, sweating, and inconsolable?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
Please answer questions 29-43 about your child’s daytime behavior in the PAST 4 WEEKS.
29. Does your child wake up by him/herself in the morning?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
30. Does your child wake up in a negative mood?
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Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
31. Does your child take a long time to become alert in the morning?
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Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
32. Does your child seem tired/unrefreshed in the morning?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
33. Does your child wake up with headaches in the morning?
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Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
34. Does your child have problems with sleepiness during the day?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
35. Has a teacher/supervisor commented that your child appears sleepy during the day?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
36. Does your child seem NOT to listen when spoken to directly?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
37. Does your child have difficulty organizing tasks and activities?
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Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
38. Is your child easily distracted by extraneous stimuli?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
39. Does your child fidget with hands or feet, or squirm in seat?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
40. Does your child seem “on the go” or often act as if “driven by a motor”?
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Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
41. Does your child interrupt or intrude on others (e.g., butt into conversations or games)?
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Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
42. Does your child have “sleep attacks” or cataplexy (episodes of sudden weakness)?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
43. Does your child feel paralyzed when trying to wake up or fall asleep?
*
Yes
No
Don't Know
# of days per week
*
1
2
3
4
5
6
7
Questions 46-47 are about your child’s overall health.
44. Has your child grown at a less than normal rate at any time since birth?
*
Yes
No
Don't Know
45. Does your child take any chronic medications (for longer than 4 weeks)?
*
Yes
No
Don't Know
Medication List
Medicine
Reason for Taking Medicine
Dose
# Doses per Day
Add
Remove
For questions 46-49, “usually” means more than half the time.
46a. How much total sleep in a 24 hour periodic does your child get on weekdays?
*
0 hours
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
13 hours
14 hours
15 hours
16 hours
17 hours
18 hours
19 hours
20 hours
21 hours
22 hours
23 hours
24 hours
46b. How much total sleep in a 24 hour periodic does your child get on weekends or vacation?
*
0 hours
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
13 hours
14 hours
15 hours
16 hours
17 hours
18 hours
19 hours
20 hours
21 hours
22 hours
23 hours
24 hours
47. How long does it usually take your child to fall asleep each night? (minutes)
*
Please enter a number from
0
to
1440
.
48a. What time does your child usually go to bed on weekdays?
*
Hours
:
Minutes
AM
PM
AM/PM
What time does your child usually wake up on weekdays?
*
Hours
:
Minutes
AM
PM
AM/PM
48b. What time does your child usually wake up on weekdays?
*
Hours
:
Minutes
AM
PM
AM/PM
What time does your child usually wake up on weekends or vacation?
*
Hours
:
Minutes
AM
PM
AM/PM
49a. How many hours does your child usually nap during the day on weekdays?
*
0 hours
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
13 hours
14 hours
15 hours
16 hours
17 hours
18 hours
19 hours
20 hours
21 hours
22 hours
23 hours
24 hours
49b. How many hours does your child usually nap during the day on weekends or vaction?
*
0 hours
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
7 hours
8 hours
9 hours
10 hours
11 hours
12 hours
13 hours
14 hours
15 hours
16 hours
17 hours
18 hours
19 hours
20 hours
21 hours
22 hours
23 hours
24 hours
Question 50 is specifically about when your child was an infant.
50. Right after your child was born, did they require any of the following: (check all that apply):
*
Apnea Monitor
Caffeine
Oxygen
Pulse Oximeter
None of these
Other
Please describe:
*
For questions 51-54, please indicate whether your child has had any of the procedures or diagnoses listed.
51. Has your child ever had surgery to remove tonsils and/or adenoids?
*
Yes
No
52. Has your child ever been treated at home with Continuous, Bi-level, or Variable Positive Airway Pressure (CPAP, Bi- PAP or VPAP)? This machine helps keep the airway open using a mask that is placed over the nose and or mouth.
*
Yes
No
53. Has your child ever had polysomnography (an overnight sleep study) at another facility?
*
Yes
No
If yes, at what facility?
*
54. Has a provider ever diagnosed your child with sleep apnea or sleep disordered breathing?
*
Yes
No
Questions 55-56 pertain to household and immediate family members.
55. Does anyone who lives at home work variable shifts such as night shift?
*
Yes
No
56. Has a provider ever diagnosed an immediate family member with sleep disordered breathing or sleep apnea?
*
Yes
No
If yes, which family member(s)? (check all that apply)
*
Mother
Father
Brother
Sister
Grandmother
Grandfather
Other
Questions 56-58 are specifically about school (preschool/daycare) and attendance.
56. Current Grade in School
*
57. How many absences this year (estimated):
*
58. How many morning tardies this year:
*
Patient's Name
*
First
Last
Patient's Date of Birth
*
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Form Completed By
*
First
Last
Relationship To Patient
*
Mother
Father
Other
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