Dr Leigh Martens

Self-Assessments

Please answer every question.

Over the past two weeks or more, how often have you noticed or been concerned about any of the following statements in your child?

Question	Almost Never	Sometimes	Often	Very Often
1: My child has trouble falling asleep at night time, even when he/she goes to bed at a reasonable bedtime
2: When my child can’t sleep, they worry that they won’t be able to fall asleep
3: When my child wakes during the night, they have trouble going back to sleep
4: Trying to fall asleep makes my child anxious
5: My child is sleepy during the day as result of their poor sleeping patterns
6: Feels desperate, distressed or deeply disillusioned about their poor sleeping habits