Pediatric Sleep Intake Form

Chief Complaint

Pediatric Sleep Intake Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your Pediatric Sleep Form. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 20 minutes to complete, If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? General Information: 1. What is your child's date of birth? 2. What is your child's gender? - Male - Female 3. Describe your child's birth history. 4. Describe your child's developmental history. 5. Describe your child's past medical history. 6. Describe your child's past surgical history. 7. Does your child have any known allergies? Yes/No (If no, move on. If yes, ask: "Which ones?" only if the user does not provide further details after saying yes.) 8. Describe your family history. 9. Is your child's immunization status up to date? Yes/No (If no, move on. If yes, ask: "Which ones?" only if the user does not provide further details after saying yes.) Pediatric Sleep Questionnaire: 10. Does your child snore more than half of the time? Yes/No/Don't know 11. Does your child always snore? Yes/No/Don't know 12. Does your child snore loudly? Yes/No/Don't know 13. Does your child have "heavy" or loud breathing while sleeping? Yes/No/Don't know 14. Does your child have trouble breathing, or struggle to breathe while sleeping? Yes/No/Don't know 15. Have you ever seen your child stop breathing during the night? Yes/No/Don't know 16. Does your child tend to breathe through the mouth during the day? Yes/No/Don't know 17. Does your child have a dry mouth on waking up in the morning? Yes/No/Don't know 18. Does your child occasionally wet the bed? Yes/No/Don't know 19. Does your child wake up feeling un-refreshed in the morning? Yes/No/Don't know 20. Does your child have problems with sleepiness during the day? Yes/No/Don't know 21. Has a teacher commented that your child appears sleepy during the day? Yes/No/Don't know 22. Is it hard to wake your child up in the morning? Yes/No/Don't know 23. Does your child wake up with headaches in the morning? Yes/No/Don't know 24. Has your child stopped growing at a normal rate at any time since birth? Yes/No/Don't know 25. Is your child overweight? Yes/No/Don't know 26. Does your child often not seem to listen when spoken to directly? Yes/No/Don't know 27. Does your child have difficulty organizing tasks and activities? Yes/No/Don't know 28. Is your child easily distracted by extraneous stimuli? Yes/No/Don't know 29. Does your child fidget with hands or feet or squirm in seat? Yes/No/Don't know 30. Is your child "on the go" or acts as if "driven by a motor"? Yes/No/Don't know 31. Does your child interrupt or intrude on others (e.g., butts into conversations or games)? Yes/No/Don't know 32. Please upload any relevant medical reports or images you would like the doctor to review. End. (Show the following information when questionnaire complete) Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.