Your name____________________
Your age_____________________
Do you have difficulty falling asleep?_______________________
Do you awaken frequently?_______
Do you or have you had night terrors?________At what age did they begin?___________________
What is the frequency of your night terrors?_____x per night, _____x per week.
Do you have sleep apnea or stop breathing during sleep?__________
Do you wear a CPAP when sleeping?_____________________
Do you take any medications for your sleeping problems?_________
What are they?________________