SLEEP DISORDER CENTER
Pediatric Questionnaire
Fields marked with an asterisk (
*
) are required.
Child's Last Name:
Required
Child's First Name:
Required
Child's FMP+Sponsor SSN:
Required
School Grade:
Required
Child's Date of Birth:
Required
Child's Age:
Required
Gender:
Male
Female
Address:
Required
City
Required
State:
Required
Zip Code:
Required
Home Phone (xxx-xxx-xxxx):
Please enter valid Phone Number
Mothers Name:
Required
Mother Cell:
Required
Work:
Fathers Name:
Required
Father Cell:
Required
Work:
Personal Parents Email: Mother
Required
Father
Required
Referring or Primary Care
Physician Name:
Required
Location:
Required
SLEEP PROBLEMS
What are your major concerns about your child's sleep?
Required
What have you previously tried to help this problem?
Required
Has your child had any previous Sleep Studies?
Required
Date & Location:
Do you have the report?
Yes
No
SLEEP TIMES
Total estimated hours of sleep on a weekday (including naps):
Required
Usual bedtime on
weekday nights:
Required
Usual time child
begins to sleep:
Required
Usual wake time on weekday mornings:
Required
Total estimated hours of sleep on a weekend (including naps):
Required
Usual bedtime on
weekend nights:
Required
Usual wake time on
weekend morning:
Required
NAP SCHEDULE
Number of days each
week that child naps:
Required
Nap Times (from
when to when):
Required
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?
Who generally puts
the child to bed?
Required
How much time does
the child spend in their
room before going to bed?
Required
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
Mother Age:
Required
Occupation:
Required
Father Age:
Required
Occupation:
Required
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:
Required
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
Required
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:
Required
Environmental Allergies (foods, mold,
latex, insect stings, pet danger,
dust, pollen,trees, dust mites):
Medications (Name, Dose, Schedule):
Required
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?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
b. Feel worse at night?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
c. Get better with movement (wiggling feet, toes, or walking?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
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?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
b. Feel worse at night?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
c. Get better with movement (wiggling feet, toes, or walking?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
3. Does your child fidget or wiggle your feet or toes a lot when sitting or lying down?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
4. Does your child have jerking or kicking movements in his/her toes or legs or the whole body while sleeping?
Never
Occasionally (less than 1x/month)
Sometimes (1-2x/month)
Frequently (1-2x/wk to daily)
Do not know
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and ensure all required fields have been completed. A larger computer screen will work best.