Bedtime Routine Checklist
Track your nightly tasks and ensure a smooth bedtime routine every night.
Your Full Name
*
First Name
Last Name
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What time did you start your bedtime routine?
Hour Minutes
AM
PM
AM/PM Option
Which of these tasks did you complete as part of your bedtime routine?
*
Brushed teeth
Washed face
Changed into pajamas
Used the bathroom
Read a book or listened to a story
Put away electronic devices
Set alarm for the next day
Prepared clothes for tomorrow
Had a glass of water
Other
Did you skip any tasks tonight? If yes, please specify which ones and why.
How easy was it to follow your bedtime routine tonight?
*
Very Difficult
1
2
3
4
Very Easy
5
1 is Very Difficult, 5 is Very Easy
How do you feel right before going to bed?
Calm and relaxed
A little restless
Stressed or anxious
Excited for tomorrow
Other
Do you need help or reminders with any part of your bedtime routine?
Yes
No
Is there anything you would like to improve or add to your bedtime routine?
Additional notes or comments
Who is completing this checklist?
*
Self
Parent/Guardian
Caregiver
Submit Checklist
Should be Empty: