NAME OF PERSON COMPLETING QUESTIONNAIRE: Relationship to child: Referred by*:

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1 OREGON HEALTH & SCIENCE UNIVERSITY SLEEP DISORDERS MEDICINCE CLINIC PEDIATRIC SLEEP QUESTIONNAIRE SCHOOL AGED CHILDREN (4 12 year old) TO BE COMPLETED BY PARENT NAME OF PATIENT: DATE OF BIRTH: / / NAME OF PERSON COMPLETING QUESTIONNAIRE: Relationship to child: _ Referred by*: dictated Address: * May we send reports to these providers? Phone: Fax: check one Yes No Pediatrician*: Address: Phone: Fax: What are your major concerns regarding your child s sleep? What do you think is causing your child s sleep problem? FAMILY INFORMATION: Please list all members of the household Name/Relationship to Child Age Child Lives With (Indicate full-time or part-time)

2 Page 2 What is mother s education? Mother s occupation? Does mother work outside of home? Yes No job If yes, mark each label that best describes work: Day shift Evening shift Night shift (graveyard) Changing shifts Full time Part time One job More than one What is father s education? Father s occupation? Does father work outside of home? Yes No If yes, mark each label that best describes work: Day shift Evening shift Night shift (graveyard) Changing shifts Full time Part time One job More than one job Please list family members (parents, grandparents, siblings, aunts/uncles) with a history of any SLEEP-PROBLEMS (including: loud snoring/obstructive sleep apnea, excessive sleepiness/narcolepsy, restless legs/periodic leg movements, insomnia, other sleep problems). Family Member Problem Type of Sleep Has anyone in your family ever had a car accident caused by sleepiness (not due to alcohol or drugs)?

3 Yes No Don t Know If yes, whom: Type of accident: Please list any family members with a significant mental health condition (such as depression, anxiety, alcoholism/substance abuse). Family Member Type of Mental Health Problem Page 3 SLEEP HISTORY (GENERAL) What time does your child usually go to bed on school nights? Range: am/pm to am/pm What time does your child usually wake up on school days? Range: am/pm to am/pm What time does your child usually go to bed on weekend nights? Range: am/pm to am/pm What time does your child usually go to bed on weekend mornings? Range: am/pm to am/pm What is the main reason your child goes to bed at a particular time? (Check one below) Because it fits best with the families schedule Because he/she feels sleepy then Because that is when his/her TV shows are over To get enough sleep for the following day s activities Other (describe briefly):

4 IN AN AVERAGE ONE-WEEK PERIOD, HOW OFTEN DOES YOUR CHILD (check one answer for each question; please feel free to comment) Everyday /night times times times Never Comments Snore? Snore Loudly & Disruptively Sleep Restlessly Sleep in Abnormal Positions Sweat while Sleeping Complain of Headache On Wakening Have Nightmares Sleepwalk Sleeptalk Cry Out During Sleep Wake Up at Night Get Out of Bed at Night Complain About his/her Sleep Complain of Pain at Night Wet the Bed Page 4 Has your child ever used medications (over-the-counter or prescription) including herbal or natural remedies to help with sleep? Yes No Don t Know If yes, name of medication and how frequently used: _ Does your child currently (within the past month) use medications (over-the-counter or prescription) to help with sleep? Yes No Don t Know If yes, name of medication and how frequently used: _ RESTLESS SLEEP Does your child appear restless while sleeping (thrashing around, banging feet against wall, twisting covers, or falling out of bed)? Check one Never Occasionally (less than 1x/month)

5 Sometimes (1 2 x/month) only in the past Frequently (1 2x/wk to daily) Does your child seem more restless, fidgety or hyperactive that most children his/her age? Check one Never Occasionally (less than 1x/month) Sometimes (1 2 x/month) Frequently (1 2x/wk to daily) Only in the past Has anyone in the family (including grandparents, aunts/uncles) been diagnosed with restless legs or periodic leg movements during sleep? Yes No If so, who: Does anyone in the family have severe problems falling or staying asleep? No If so, who: Type of problem, if known: Yes Has your child been diagnosed with anemia? Yes No Don t Know Date, type of anemia, and treatment, if known: SLEEP HISTORY DAYTIME SLEEPINESS What usually wakes up your child in the morning? (check one below) Alarm clock Need to go to bathroom Parent or other family member Spontaneous Noise Other (describe briefly) Page 5 Which of the following applies to waking your child in the morning? (check one below) I almost always have great difficulty getting him/her out of bed. I sometimes have difficulty getting him/her out of bed. I seldom have difficulty getting him/her out of bed. I never have difficulty getting him/her out of bed.

6 During the LAST TWO (2) WEEKS, has your child struggled to stay awake (fought sleep) or fallen asleep in the following situation? (Mark one answer for every item) Struggle to Stay awake Fallen Don t Does not No (fought sleep) Asleep Know Apply In face-to-face conversations Traveling in a bus, train, place or car Attending a performance (movie, Concert, play) Watching TV Listening to the radio/stereo Reading, studying or doing homework During a test In a class at school While doing work on a computer Playing video games Riding a bicycle Eating a meal MEDICAL HISTORY Were there any complications/problems with this pregnancy or delivery (prematurity, high blood pressure, etc)? What was the birth weight? Was your child ever on an apnea monitor at home? Yes No If yes, how long? Does your child have any significant health problems? Yes No If yes, please describe: Page 6 Has your child ever had any operations (other than tonsils/adenoid removal)? Yes No

7 If yes, type of operation? Year Have your child s tonsils or adenoids been removed? Tonsils Yes No What age? What reason: Year Year Adenoids Yes No What age? What reason: Describe briefly any changes you noticed in your child s sleep or waking behavior after removal of tonsils/adenoids: If NO, do you think the tonsils or adenoids are a problem? Yes No Don t Know For how long have they been a problem? Years Has your child ever broken his/her facial bones? Yes No Does your child have difficulty breathing through his/her nose? Yes No In the past year, has your child had strep throat/tonsillitis? Yes No Frequent colds/respiratory infections? Yes No Frequent sinus infections? Yes No Does your child have allergies? Probably Yes No If yes, what: Allergies to medications: Does your child have asthma? Yes No If yes, please answer the following questions: In the past year..... How many days has your child missed school due to asthma? None How many days has your child been hospitalized for asthma? None List any medications your child takes for asthma:

8 Type: Type: Type: Frequency: Frequency: Frequency: Does your child frequently complain of heartburn? Yes No Don t Know Has he/she ever been diagnosed with gastroesophageal (stomach) reflux? Yes No Only when younger Page 7 Has your child had any head injuries requiring medical evaluation and/or treatment or loss of consciousness? Yes No If yes, please describe: List any prescription or over-the-counter medications your child has taken in the last month: Type: Reason for Med: Type: Type: Reason for Med: Reason for Med: Do you have additional comments about your child s medical history? (continue on additional sheet if necessary) HEALTH HABITS Please answer the following questions regarding health habits which may impact sleep. In the past two (2) weeks, on average: How much caffeinated soda does your child drink? More than 3 glasses per day Between 1 and 3 cups per day

9 Less than 1 cup per day None Don t know How much television does your child watch on school days? 0 2 hours per day between 2 and 4 hours between 4 and 6 hours between 6 and 8 hours More than 8 hours don t know How much television does your child watch on weekend days? 0 2 hours per day between 2 and 4 hours between 4 and 6 hours between 6 and 8 hours More than 8 hours don t know Does your child watch TV in the 30 minutes before falling asleep? Every night 5 6 nights 3 4 nights 1 2 nights Not at all Page 8 Does your child have a television set in his/her bedroom? Yes No DEVELOPMENT HISTORY PART A In what grade is your child currently enrolled? grade What school does your child attend this year? Has your child been diagnosed with: Yes No Comments Dyslexia Speech Impairment Mental Retardation Behavioral Disorder Depression/Anxiety Attention Deficit Disorder (ADHD) Other learning disorder

10 Please specify: Is your child enrolled in any special education (special needs) classes in school? Yes No Please describe: Does your child have and Individualized Education Plan (IEP) provided by the school? Yes No Please describe: DEVELOPMENT HISTORY PART B Does your child have any significant behavioral or mental problems? Yes No Please describe: _ Has your child ever received counseling for behavioral or mental health problems? Yes No If yes, what reason: Have you or your spouse ever been seen by a mental health counselor for concerns regarding your child? Yes No If yes, what reason: Page 9 To what organized groups does your child currently belong? (E.g., team sports, scouts, church, groups, etc.)

11 SLEEP BELIEFS In order to better understand your sense of the average child s sleep, please answer the following questions based on your belief for an average child (your child s age) who does not have a sleep problem. How many hours of sleep per night does the average child get? hrs How long does it take the average child to get to sleep? minutes How many times does the average child wake up during the night? times How long does the average child spend awake in bed during the night minutes Or hours Do you think most children get enough sleep? Yes No Don t Know Thank you for taking the time to complete this questionnaire!!!!