PEDIATRIC HISTORY FORM

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1 Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer. Bring this form with you to your child s sleep study. Child s Name Today s Date First Middle Last Date of Birth Age Height Weight Male or Female Address Mother s Name Telephone (home) Telephone (work) Father s Name Telephone (home) What is your ethnic background (this question is optional)? (circle) Telephone (work) Caucasian Asian/Pacific Islander/Oriental American Indian/Alaskan Native Hispanic African American Other (specify) REFERRING PHYSICIAN Name Telephone Address If there are other physicians to whom you would like a copy of your child s sleep study sent, please provide full names and addresses below. In your own words, please describe the reason you and/or your physician is seeking evaluation of your child s sleep. Include any information regarding previous sleep studies, if applicable.

2 Please describe your child s usual bedtime routine. When your child goes to bed at night, he/she... Reads Does Homework Talks on Phone Listens to Music Watches TV Plays Video Games Uses Computer/Internet (other) How many nights per week does your child sleep in the same room as you nights or another primary caretaker? Does your child have his own bedroom? Yes No Does your child share his bedroom with another child? Yes No Does your child have his own bed? Yes No Does your child have a regular bedtime? Yes No School Nights or Weekdays Weekends or Vacations What time does your child go to bed? AM / PM AM / PM What time does your child wake up? AM / PM AM / PM How long does it usually take for your child to fall asleep? minutes / hours minutes / hours How many times does your child usually wake up a night? times times If your child does wake up during the night, how long does it usually take him to go back to sleep? minutes / hours minutes / hours How much sleep do you estimate your child gets on a typical night? hours hours What is your child s usual sleeping position? How would you describe the quality of your child s sleep? Stomach Back Excellent Good Side Propped Up With Pillows Fair Poor 2

3 Does your child have difficulty falling asleep? Yes No If yes, why do you think your child has difficulty falling asleep? Does your child have difficulty staying asleep? Yes No If yes, why do you think your child has difficulty staying asleep? Is your child excessively sleepy or tired during the day? Yes No Does your child fall asleep at school? Yes No Is your child s daytime performance at school, work, or recreation less efficient than you would like it to be? Yes No How often does your child nap? Number of Times per Day or Week Duration: Time of Day: Does your child have any of the following symptoms routinely (once a week or more) during sleep? Symptoms Yes No If yes, Age of Onset If yes, Days per Week Snoring Snorting Mouth Breathing Choking/Gasping During Sleep Pauses in Breathing During Sleep Struggling to Breathe/Labored Breathing During Sleep Change in Skin Color Sweating During Sleep Restless Sleep Nightmares Frequent Nighttime Awakenings Awakening Frightened or Screaming Bed Wetting TeethGrinding Sleep Talking Sleep Walking 3

4 Does your child have any of the following symptoms routinely (once a week or more) during sleep? Morning Headaches Symptoms Yes No Excessive Daytime Sleepiness... while reading / watching TV / riding in a car Sleepiness at School Recent Decrease in School Performance Missed School or Late to School Behavioral Concerns Tiredness or Fatigue Hyperactivity Poor Concentration Over Aggressiveness Irritability or Mood Swings Frequent Leg Movements During Sleep Frequent Leg Pains or Leg Discomfort Creepy, Crawly Feelings in Legs If yes, Age of Onset If yes, Days per Week Is there anything else that is unusual about your child s sleep patterns or breathing during sleep? Yes No If yes, please explain. Does your child have any of the following symptoms? Nasal Congestion Yes No (number of days/week) (number of nights/week) Noisy Breathing Yes No (number of days/week) (number of nights/week) Wheeze Yes No (days / week) (nights / week) With exercise? Yes No Cough Yes No (days / week) (nights / week) With exercise? Yes No Difficulty Breathing Yes No (days / week) (nights / week) With exercise? Yes No SURGICAL HISTORY Yes No Date of Surgery 4

5 Enlarged Tonsils Enlarged Adenoids Facial Abnormality Sinus Bronchoscopy Nasal Polyp Others (If yes, please list below) MEDICAL HISTORY Yes No Age of Onset Enlarged Tonsils Enlarged Adenoids Recurrent Ear Infections Seasonal Allergies or Hay Fever Recurrent Polyps Recurrent Croup Asthma Failure to Gain Weight Rapid or Excessive Weight Gain 5

6 MEDICAL HISTORY Yes No Age of Onset Attention Deficit Hyperactivity Disorder Facial Abnormality Neurological or Muscular Disorder Seizure Disorder Genetic Abnormality Down Syndrome Autism Developmental Disability Anxiety Depression BIRTH HISTORY Full Term or Pre-Term ( number of weeks early ) ( circle one) Were there any complications during pregnancy or delivery? Yes No If yes, please describe. GROWTH & DEVELOPMENT IMMUNIZATIONS up to date? Yes No 6

7 SOCIAL HISTORY Lives With... Pets? Yes No If yes, list type (cat, dog, bird, etc.) Attends Day Care? Yes No If yes, number of days / week School? Yes No Grade Please list any concerns from teachers as well as any concerns you have regarding your child s behavior. Does your child participate in sports? Yes No Is your child exposed to smoke? Yes No Caffeine Intake (list times & amounts per day). MEDICATION HISTORY Please list any medications your child is currently taking. Include over-the-counter medications, vitamins, etc. Name of Medication Dosage How Often 7

8 FAMILY HISTORY Father Mother Son/Daught er Brother/Sist er Brother/Sist er Living Dead Age Snoring Daytime Sleepiness Sleep Apnea Asthma Hay Fever Tuberculosis Pulmonary Embolism (clot in lung) Emphysema Bronchitis Pulmonary Fibrosis (scarring in lung) Lung Cancer Other Cancer High Blood Pressure Heart Attack Angina Stroke Diabetes Kidney Disease Thyroid Disease Anemia Arthritis Ulcer Disease Intestinal Disease Glaucoma 8

9 PREVIOUS EVALUATIONS Has your child had a sleep study in the past? Yes No If yes, where and when was the study done? What were the results? Please list any treatment(s) tried. Does your child use CPAP / Bi-Level PAP / supplemental oxygen therapy? Yes No If yes, what are the settings? Does your child snore while utilizing CPAP or Bi-Level PAP? Yes No Have you been told that your child stops breathing during sleep while utilizing CPAP or Bi-Level PAP? Yes No Does your child wake up frequently during the night? Yes No Is your child sleepy during the day? Yes No 9

10 Please list any medical equipment (CPAP, feeding pump, oxygen, etc.) that your child is utilizing at home. Please list any monitors (pulse oximeter, apnea monitor, etc.) that you are utilizing at home. What is the name and location of the home care company providing the above-listed medical equipment? How likely is your child to doze off or fall asleep in the following situations? This refers to your usual way of life in recent times (over the last three months). Use the scale to the right to choose the most appropriate number for each situation. 0 = No Chance of Dozing 1 = Slight Chance of Dozing 2 = Moderate Chance of Dozing 3 = High Chance of Dozing SITUATION CHANCE OF DOZING 1. Sitting and reading. 2. Watching television. 3. Sitting inactive in a public place (theater, meeting) 4. As a passenger in a car for an hour without a break. 5. Lying down to rest in the afternoon when circumstances permit. 6. Sitting and talking to someone. 7. Sitting quietly after lunch. 8. In a car, while stopped for a few minutes in traffic. Please bring this completed form to your sleep study appointment. 10

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