Sleep Questionnaire

Please complete all the below sections to enable analysis of the challenge. Once received, Admin will schedule a plan development meeting to work colalboratively to develop a plan.

Client Name

DOB

What time does your child go to bed?

How long does it take to fall asleep at night?

Does your child wake overnight?

YESNO

How frequently do they wake and how long would they wake for?

What support do they need to return to sleep?

Please explain your bed time routine.

Does your child Nap during the day?

YESNO

How many naps and for how long?

How long do they take to get to sleep for a nap and what support do they need?

Please explain your nap time routine.

Epworth Sleepiness Scale

How likely are they to doze off or fall asleep in the following situations, in contrast to feeling just tired?

If you have not done some of these things recently, select unknown. Tick the MOST APPROPRIATE CHOICE for each situation in the table below:It can also include paragraphs.

Sleep Quality

Does your child snore?

YESNO

Your snoring is?

Slightly louder than breathingAs loud as talkingLouder than talkingVery loud- hear outside of the room

Does your child have a history of:

TonsilitisEar InfectionsRespiratory conditions

If you selected any of the above, please explain medical history.

Does your child appear restless in bed?

YESNO

Does your child present with any of the following

Parent Name

Signature

Draw signature|Type signatureClear

Date

Thank you for completing this form.

The information provided will be Saved to your client file.

Admin will be in contact to schedule your 1:1 with your OT, if not already scheduled. Your OT may email you subsquent forms for completion to enable data analysis at your meeting.

If you have any questions, please contact admin@tteam.com.au or call 02 9621 2504 who can help you further.