Pediatric Sleep History
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- Juliet Long
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1 Fax Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip: Telephone (Best for contact): Messages allowed at this number: Yes No What is the child s/ your primary sleep concern? How long has this been going on for? Are there any other problems that you ve noticed or sleep concerns that you have? Has the patient ever been diagnosed with a sleep problem in the past? No Yes If yes, what was the diagnosis and recommended treatment(s)? Sleep Schedule Weekday Bedtime: am pm Weekday Wake up time: am pm Weekend Bedtime: am pm Weekend Wake up time: am pm How often does your child typically wake up during the night? Does your child usually wake up refreshed from sleep? Does your child typically take naps during the day? No Yes If yes, how many? Typical nap length: Typical time for nap(s): 1
2 Fax Sleep Environment Does your child share a bedroom with anyone else, including pets? No Yes If Yes, please list all others in the child s bedroom at night. Does your child have a TV, video game, smart phone, or tablet in their room at night? No Yes Does your child like to read in bed at night? No Yes Does your child eat meals or snacks in bed? No Yes Are there any lights on in the room while your child is sleeping? No Yes No Yes If Yes, please describe: Are there any sounds/noises in the room while the child is sleeping? Sleep Observation Has your child ever been observed to do, or complained of, any of the following while sleeping: Snoring Gasping for air Seizures Stopping breathing Kicking their legs Jaw Pain Acting out dreams Bed Wetting (Frequency ) Bad Dreams/ Night Terrors Teeth Grinding Other Caused injury to themselves or others Sleep Talking Sleep Walking Frequent Awakenings Strange body movements How long does it typically take your child to fall asleep? Does your child have a bedtime routine? No Yes If Yes, please describe: Please list the relationships and ages of all persons living at the child s home (example: Mother 38, Brothers 7 and 12): 2
3 Fax Daytime Observations Have any of the following symptoms been noticed in your child during the daytime? Difficulty paying attention in school Trouble focusing on one task Learning difficulties or disability Drug/ Tobacco use Behavioral difficulties Trouble staying awake at school Anxiety/ Panic attacks Moodiness Hyperactivity/ ADHD Feelings of muscle weakness or loss of muscle control (possible associated with strong emotions such as laughter or anger) Depression Other concerning observations Does your child consume products containing caffeine? (soft drinks, coffee, tea, chocolate) No Yes If Yes, how often and what do they typically consume? Medical History Has your child ever had their tonsils removed? No Yes Has your child ever had their adenoids removed? No Yes Has your child ever had ear tubes inserted? No Yes Please list any hospitalizations or surgeries your child has had (including approximate dates): 3
4 Fax Please check any that apply to your child: Frequent nasal congestion/ Sinus problems Hearing problems Chronic bronchitis or cough Speech problems Asthma Headaches Frequent ear infections Cerebral palsy Difficulty swallowing Heart disease Acid Reflux Genetic disease Seizures Down s Syndrome Delayed or poor growth Skeletal problems Excessive weight Craniofacial disorders Vision problems Pain Additional medical history not included above: Family History Does anyone in the child s family have a sleep disorder? No Yes If Yes, please indicate the disorder and family member(s) that has it: Insomnia Mother Father Sibling Other Snoring Mother Father Sibling Other Sleep Apnea Mother Father Sibling Other Restless Leg Syndrome Mother Father Sibling Other Periodic Limb Movement Mother Father Sibling Other Narcolepsy Mother Father Sibling Other Sleep Walking Mother Father Sibling Other Sleep Talking Mother Father Sibling Other Night Terrors Mother Father Sibling Other Other Mother Father Sibling Other 4
5 Fax School Performance Child s Grade: Has your child ever repeated a grade? No Yes If yes, which grade? Is your child enrolled in any special education classes? No Yes How many days of school has your child missed so far this year? How many days of school did your child miss last year? Child s grades this year: Excellent Good Average Poor Failing Child s grades last year: Excellent Good Average Poor Failing Medication List Drug Allergies: Medication Dose Frequency 5
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