PATIENT INFORMATION
CHILD'S INFORMATION
What are your major concerns about your child’s sleep?
What things have you tried to help your child’s problem?
SLEEP HISTORY
Weekend/Vacation/Weekday Sleep Schedule Write in the amount of time child sleeps during a 24-hour period on weekdays (add daytime and nighttime sleep):
Write in the amount of time child sleeps during a 24-hour period during weekends and vacations (add
daytime and nighttime sleep):
NAP SCHEDULE GENERAL SLEEP SLEEP EVAULATION QUESTIONNAIRE - NIGHTIME SYMPTOMS
19. Wets bed:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
SLEEP EVALUATION QUESTIONNAIRE - DAYTIME SYMPTOMS
1. Trouble getting up in the morning:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
2. Falls asleep in school:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
3. Naps after school:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
4. Daytime sleepiness:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
5. Feels weak or loses control of his/her muscles with strong emotions:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
6. Reports unable to move when falling asleep or upon waking:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
7. Sees frightening visual images before falling asleep or upon waking:
Never (does not happen) Not often (less than 1 night/day per week) Often (3-5 nights/days per week) Always (6-7 nights/days per week) Do not know
PREGNANCY / DELIVERY
Pregnancy: Normal Difficult
Delivery: Term Pre-Term Post-Term
Child's Birthweight:
Only child? Yes No
If no, choose birth order: 1st 2nd 3rd 4th 5th 6th 7th
MEDICAL HISTORY
PAST PSYCHIATRIC/PSYCHOLOGICAL HISTORY
CURRENT MEDICATION HISTORY
Please list any medications your child currently takes (List medicine, dosage and how often):
LONG-TERM MEDICAL PROBLEMS
If your child has long-term medical problems, please list the three you think are most
important.
SURGERIES / HOSPITALIZATIONS
Has your child ever had his/her tonsils removed? Yes No
Has your child ever had his/her adenoids removed? Yes No
Has your child ever had ear tubes? Yes No
Please list any additional hospitalizations or surgeries:
HEALTH HABITS
Does your child drink caffeinated beverages? (e.g., Coke, Pepsi, Mountain Dew, iced tea) Yes No
SCHOOL PERFORMANCE
Your child's grade:
Has your child ever repeated a grade? Yes No
Is your child enrolled in any special education class? Yes No
How many school days has your child missed so far this year?
How many school days did your child miss last year?
How many school days was your child late so far this year?
How many school days was your child late last year?
Child's grades this year: Excellent Good Average Poor Failing
Child's grades last year: Excellent Good Average Poor Failing
FAMILY'S INFORMATION
List all persons living in the home (including name, relationship and age):
FAMILY SLEEP HISTORY
Does anyone in the family have a sleep disorder? Yes No
If yes, mark the disorders:
Insomnia: Mother Father Brother/sister Grandparent
Snoring: Mother Father Brother/sister Grandparent
Sleep apnea: Mother Father Brother/sister Grandparent
Restless legs syndrome: Mother Father Brother/sister Grandparent
Periodic limb movement disorder: Mother Father Brother/sister Grandparent
Sleeping walking/sleep terrors: Mother Father Brother/sister Grandparent
Sleeping talking: Mother Father Brother/sister Grandparent
Narcolepsy: Mother Father Brother/sister Grandparent
REFERRAL
Who asked that your child be seen by a sleep specialist?
Pediatrician/family physician Child's parent or guardian Surgical specialist (e.g. ENT) Pediatric specialist (e.g. allergist, neurologist, pulmonologist) Mental Health Specialist (e.g. psychiatrist, psychologist, social worker) School teacher, nurse, counselor Child himself/herself Other
Name of person who referred you:
EPWORTH SLEEPINESS SCALE - CHILDREN
How likely is your child to doze off or fall asleep in the following situations, in contract to feeling “just tired”? This refers to their usual way of life in recent times. Even if they have not done some of these things recently, think about how they would have affected your child. Use the following scale to choose the moset appropriate number for each situation.
0 = Would Never Doze
Sitting and Reading: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Watching TV: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Sitting, inactive in a public place (theatre or classroom): 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
As a passenger in a care for an hour without a break: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Lying down to rest in the afternoon when circumstances permit: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Sitting and talking to someone: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Sitting quietly after lunch: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
Doing homework or taking a test: 0 - Never 1 - Slight Chance 2 - Moderate Chance 3 - High Chance
