Child's Date of Birth:

Child's Age:

Gender:

Male Female

Address:

Home Phone (xxx-xxx-xxxx):

Mothers Name:

Mother Cell:

Work:

Fathers Name:

Father Cell:

Work:

Personal Parents Email: Mother

Father

SLEEP PROBLEMS

What are your major concerns about your child's sleep?

What have you previously tried to help this problem?

Has your child had any previous Sleep Studies?

Date & Location:

Do you have the report? Yes No

SLEEP TIMES

Total estimated hours of sleep on a weekday (including naps):

Usual bedtime on
weekday nights:

Usual time child
begins to sleep:

Usual wake time on weekday mornings:

Total estimated hours of sleep on a weekend (including naps):

Usual bedtime on
weekend nights:

Usual wake time on
weekend morning:

NAP SCHEDULE

Number of days each
week that child naps:

Nap Times (from
when to when):

HEALTH HABITS

Does anyone smoke in the home?

Yes No

Does the child drink caffeinated
drinks (Pepsi, Mountain Dew,
Red Bull, Tea or Coffee)?

Yes No

If yes, Amount per day? What time would
child have last
beverage before bed?

GENERAL SLEEP INFORMATION

Is there a regular bedtime routine?

Yes No

Does the child have his/her own bedroom?

Yes No

Does the child have his/her own bed?

Yes No

Is there a parent present when your child falls asleep?

Yes No

Does the child resist going to bed?

Yes No

Does the child have difficulty falling asleep?

Yes No

Does the child awaken during the night?

Yes No

Does the child have difficulty returning to sleep if awakened at night?

Yes No

Is the child difficult to awaken in the morning?

Yes No

Is the child a poor sleeper?

Yes No

CURRENT DAYTIME SYMPTOMS

Trouble getting up in the morning?

Never Occasionally Frequently

Falls asleep at school?

Never Occasionally Frequently

Naps after school?

Never Occasionally Frequently

Daytime sleepiness?

Never Occasionally Frequently

Feels weak or loses control of his/her muscles with strong emotions?

Never Occasionally Frequently

Reports being unable to move when falling asleep or upon waking?

Never Occasionally Frequently

Reports frightening visual images before falling asleep or upon waking?

Never Occasionally Frequently

CURRENT SLEEP SYMPTOMS: DOES THE CHILD HAVE

Stops breathing during sleep?

Yes No

Snores?

Yes No

Restless sleep?

Yes No

Sweating when sleeping?

Yes No

Poor appetite?

Yes No

Nightmares?

Yes No

Sleepwalk?

Yes No

Talking in their sleep?

Yes No

Screaming during sleep?

Yes No

Getting out of bed at night?

Yes No

Resistance going to bed?

Yes No

Teeth grinding?

Yes No

Bed wetting?

Yes No

If you answered "Yes" to any of the above questions, please explain:

FAMILY HISTORY

Other persons living in the home:

Does anyone in the family have a sleep disorder?

Yes No

If yes, who and what disorder?

Have any siblings been diagnosed with a Sleep Disorder or have had tonsils and/or adenoids removed?

Yes No

If yes, please describe:

PAST MEDICAL HISTORY

Pregnancy/Delivery:

Normal Difficult

Delivery:

Vaginal C-Section

Gestation:

Term Pre-Term Post-Term

If Premature or Post Mature, how many weeks?

Child's birth weight:

Is this an only child?

Yes No If no, what number child is this one?

If your child has long-term medical problems,
list the three that you think are the most important?

CHILD'S MEDICAL HISTORY (check all that apply): Frequent nasal congestion Sinus problems
Chronic bronchitis or cough Environmental allergies
Asthma Frequent colds or flu
Frequent ear infections Frequent strep throat infections
Difficulty swallowing Acid reflux (gastroesophageal reflux)
Poor or delayed growth Excessive weight
Hearing problems Speech problems
Vision problems Seizures/Epilepsy
Morning headaches Cerebral palsy
Heart disease High blood pressure
Sickle cell disease Genetic disease
Chromosome problem (e.g., Down) Skeleton problem (e.g., Dwarfism)
Craniofacial disorder (e.g., Pierre-Robin) Thyroid problems
Eczema (itchy skin) Pain
Head or Brain injury Meningitis
Autism Behavioral Disorder
Developmental Delay Learning Disabilities
Hyperactivity/ADHD Anxiety/Panic Attacks
Obsessive Gompulsive Disorder Depression
Drug use/abuse Psychiatric Admission

Comments:

Please list any additional Psychological, psychiatric, emotional or behavioral problems
diagnosed or suspected by a physician or psychologist:

PAST SURGICAL HISTORY

Has your child ever had
his/her tonsils removed?

Yes No If yes, at what age?

Has your child ever had
his/her adenoids removed?

Yes No If yes, at what age?

Has your child ever had ear tubes?

Yes No If yes, at what age?

What other surgeries has your child had (include age when surgery performed)?

Medication Allergies:

Environmental Allergies (foods, mold,
latex, insect stings, pet danger,
dust, pollen,trees, dust mites):

Medications (Name, Dose, Schedule):

SLEEPINESS QUESTIONS

Please indicate how likely your child is to doze or sleep in the following situations:

1) Sitting and reading

None Slight Moderate High

2) Watching TV

None Slight Moderate High

3) Sitting inactive in a public place (e.g. theater)

None Slight Moderate High

4) Being a passenger in a vehicle for an hour or more

None Slight Moderate High

5) Lying down in the afternoon

None Slight Moderate High

6)Sitting and talking to someone

None Slight Moderate High

7) Sitting quietly after lunch

None Slight Moderate High

8) Sitting in a car, stopped in traffic for a few minutes

None Slight Moderate High

1. Does your child ever have uncomfortable or funny feelings (creepy-crawly, tingling, burning, squeezing, etc) In your legs?

Yes No Don't know

If yes, do these funny feelings in his/her legs:

a. Seem worse when lying down or sitting?

b. Feel worse at night?

c. Get better with movement (wiggling feet, toes, or walking?

2. Does your child ever feel like you "need to" or "have to" move your legs?

Yes No Don't know

If yes, do these funny feelings in his/her legs:

a. Seem worse when lying down or sitting?

b. Feel worse at night?

c. Get better with movement (wiggling feet, toes, or walking?

3. Does your child fidget or wiggle your feet or toes a lot when sitting or lying down?

4. Does your child have jerking or kicking movements in his/her toes or legs or the whole body while sleeping?

If you are having problems submitting the questionnaire, please review your answers
and ensure all required fields have been completed. A larger computer screen will work best.

SLEEP DISORDER CENTER

Pediatric Questionnaire