Pediatric Sleep Intake Form

Chief Complaint

Pediatric Sleep Intake Form

Form Content

Hello, my name is [Your Name], and I will help you complete the questionnaire portion of your Pediatric Sleep Intake 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 45 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? Patient Information: What is patient's full name? What is patient's date of birth? What is patient's gender? Who is completing this form? What is your relation to the patient? Sleep Assessment: 6. Does your child snore more than half the time? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the frequency?") 7. Does your child always snore? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the intensity?") 8. Does your child snore loudly? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the loudness?") 9. Does your child have heavy or loud breathing while sleeping? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the breathing pattern?") 10. Does your child have trouble breathing or struggle to breathe while sleeping? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the episodes?") 11. Have you ever seen your child stop breathing during the night? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the occurrences?") 12. Does your child tend to breathe through the mouth during the day? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the frequency?") 13. Does your child have a dry mouth on waking in the morning? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the severity?") 14. Does your child occasionally wet the bed? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the frequency?") 15. Does your child wake up feeling unrefreshed in the morning? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the feeling?") 16. Does your child have a problem with sleepiness during the day? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the episodes?") 17. Does your child have problems with mood or behavior? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the issues?") 18. Has a teacher or other supervisor commented that your child appears sleepy during the day? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the comments?") 19. Is it hard to wake your child in the morning? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the difficulty?") 20. Does your child wake up with headaches in the morning? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the headaches?") 21. Did your child stop growing at a normal rate at any time since birth? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the growth pattern?") 22. Is your child overweight? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the weight concerns?") 23. Does your child often not seem to listen when spoken to directly? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the behavior?") 24. Does your child have difficulty organizing tasks and activities? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the challenges?") 25. Is your child easily distracted by extraneous stimuli? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the distractions?") 26. Does your child fidget with hands or feet or squirm in their seat? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the movements?") 27. Is your child often "on the go" or acts as if "driven by a motor"? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the behavior?") 28. Does your child interrupt or intrude on others (e.g., butts into conversations or games)? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the interruptions?") 29. Does your child is restless while trying to fall asleep? Yes/No/Don't Know 30. Does your child is restless while asleep? Yes/No/Don't Know 31. Does your child require frequent naps? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the frequency?") 32. Are your child's immunizations up to date? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you provide details?") 33. What is your child's normal bedtime? 34. What is your child's normal wake time? 35. Is the sleep schedule the same on weekends? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the differences?") 36. How long does it take for your child to fall asleep? ( short time 10-15min, or long 30min or longer ) 37. Where does your child sleep? (own bed, parent's bed, sibling's bed, other) 38. Does your child sleep on their own or co-sleep? 39. Does your child experience shortness of breath or cough during activity? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the episodes?") 40. Does your child have trouble keeping up with friends during exertion? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the challenges?") 41. Does your child have frequent cold or chest infections? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the frequency?") 42. Are the symptoms more in the nose or the chest? (nose, chest) 43. Do your child's colds frequently last more than 2 weeks and have a lingering cough? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the symptoms?") Past Medical History: 44. Was the mother's pregnancy normal? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe any illnesses or problems?") 45. Did the mother smoke, use any drugs or drink alcohol during the pregnancy? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the exposure?") 46. Was the mother on any medications during pregnancy Yes/No/Don't Know 47. Was your child born at term? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the birth timing?") 48. Was your child's birth delivery normal? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the delivery?") 49. What was yuor child Birth Weight? 50. Were there any medical interventions at birth? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the interventions?") 51 Was the child breast fed and for how long? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe?") 52. Were there any problems with latching initially? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the problem?") 53. Was the child a big spitter or vomitted frequently? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the problem?") 54. Has your child been diagnosed with any medical conditions? (Asthma, ADD/ADHD, Celiac Disease, Syndrome or Development Delays, Autism, Seizure Disorder, Anxiety, Gastric Reflux/GERD, Restless Legs, Eczema, Allergies, Croup, Snoring, Other) 55. Is your child very flexible? Yes/No/Don't Know 56 . Is there any history of developmental delays or psychiatric problems? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the problem?") 57. What are your child's current medications or treatments? 58. Does your child have any known allergies? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the allergies?") 59 . Was your child ever hospitalized, had any surgery or any Emergency visits Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the problem?") 60. If you travel elsewhere, are the symptoms better, worse, or the same? 61. Is there a seasonal pattern for the symptoms? Yes/No/Don't Know (If no, move on. If yes, ask: "Can you describe the pattern?") 62. What time or seasons are worse for the symptoms? (Fall, Winter, Spring, Summer) 63. What symptoms do you notice when they are worse?