Children’s Sleep and Bed Wetting Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.NameEmail *Phone NumberCountry *Please write a short description of your child's sleep problemDoes your child suffer from a significant health problem?YesNoWhat is the gender of your child?What is your child's ageDoes your child have a regular bedtime hour?YesNoWhere does your child fall asleepHis/her bedParents bedSiblings bedSofaOtherDoes your child refuse going to bed?AlwaysSometimesNeverHow much time does it take your child to fall asleep?More than an hourAbout 15 minutesAbout 30 minutesMore than 30 minutes Does your child wake up during the night restless, not awake, usually after about 2-3 hours from bed time (cries, angry, moving his arms or legs restlessly)NeverSometimesVery oftenDoes your child have fears at bedtime or during the night?NeverSometimesVery oftenIf your child has fears does he/she need parental reassurance to calm down and fall asleep?Not relevantNeverSometimesAll the timeDoes your child snore or sleep with his/her mouth open?NeverSometimesVery oftenIs your child sleepy or very tired during the day?NeverSometimesVery oftenHow many times does your child wake up during the night?OnceTwiceMore than twiceNeverDoes your child have nightmares?NeverOnce a weekTwice a weekMore than twice a weekDoes your child wet his/her bed at night?NeverOnce a weekTwice a weekMore than twice a weekWas there a period of complete dryness at night for at least 6 months?YesNoDoes your child wet only during the night?Only at nightOnly at daytimeBoth during night and daytimeDo you limit liquids before going to sleep or wake your child during the night to go to the toilet?NoWe limit our child from liquids before bedtimeWe wake our child to go to the toilet at nightWe limit liquids and wake our child at nightDid you try any of these treatment methods?Psychological treatmentBed wetting alarmDesmopressinOther medicationsOtherDid you rule out any medical condition regarding bed wetting? (copy)YesNoSubmit
