PLEASE COMPLETE THE FOLLOWING (CHECK PRIMARY PHONE #) Street:
Home:
City:
Work:
State & Zip Code:
Cell:
e-mail:
FAMILY / EMERGENCY CONTACT (CHECK PRIMARY PHONE #) Name:
Home:
Relationship to patient:
Work:
Cell:
SEND REPORTS TO THE FOLLOWING HEALTH CARE PROVIDERS: Name:
Location:
Phone:
Name:
Location:
Phone:
Name:
Location:
Phone:
SLEEP HISTORY Based on the last 6 months, how many hours of sleep do you usually get at night? ______________________ What is your typical bedtime? ___________________
What is your typical waking time? _______________
Do these times differ on the weekend?
If yes, how much? ___________________________
NO
YES
Where do you usually sleep? ___________________
What sleep position do you prefer? ______________
Does anyone else sleep in your room?
If yes, who? _________________________________
Do you watch TV before sleep?
NO
NO
YES
YES
Do you read in bed before sleep?
Do you use your bed for any other activities besides sleep? In the 1 hour before bed do you: NO YES Do homework Nap Eat NO YES Exercise
NO NO
NO
Use a computer YES Listen to music YES
NO
YES
YES - ___________________________________
NO
YES
NO
YES
Use a cell phone Play any games
NO
YES
NO
YES
Have you used any medications or supplements for sleep in the past? (please list) ____________________________
___________________________
____________________________
____________________________
___________________________
____________________________
Have you ever been evaluated for a sleep problem? Have you ever had sleep testing?
NEW PATIENT INFORMATION PEDIATRIC & TEEN SLEEP ONSET – PLEASE CHECK ALL THAT APPLY Difficulty falling asleep
Uncomfortable sleep environment
My mind races with thoughts when I try to fall asleep I often worry whether or not I will be able to fall asleep I need someone else with me to fall asleep (who?) _____________________________________________ I sense a presence in my room or see lifelike visions (people in room, etc) as I fall asleep I feel an inability to move as if paralyzed while trying to go to sleep Urge to move my legs / arms
Wiggle or kick to fall asleep
Often cannot find a comfortable position
Have “growing pains”
I am scared to be alone in my room
DURING SLEEP – PLEASE CHECK ALL THAT APPLY I snore / been told I snore
I gasp for breath during sleep
I sweat in my sleep
I get headaches at night
Often have a dry mouth at night
Told I stop breathing in sleep
I sense a presence in my room or see lifelike visions (people in room, etc) if I wake up I feel an inability to move as if paralyzed if I wake during the night Urge to move legs / arms I sleep walk / run
I kick a lot during sleep I sleep talk / scream
I have sleep terrors
I go to another room/bed during the night to sleep I wet the bed (how often) ____
Mouth-breather in sleep I “act-out” dreams
I wake to use the bathroom more than once/night
Difficulty remaining asleep
I grind my teeth in my sleep
IN THE MORNING & DAY – PLEASE CHECK ALL THAT APPLY I am not rested when I awaken
I feel sleepy during the day
Others say I am sleepy in day
Awaken too early
Awaken with a dry mouth
Morning headaches
Have difficulty concentrating
Have trouble remembering
I am often irritable
If you nap,
My naps are refreshing
I dream in naps
I nap out of my bed
I feel an inability to move as if paralyzed when I wake up I notice a sudden weakness or feel my body “go limp” if I laugh hard, get surprised, or get very upset (circle) Often feel depressed
Often feel anxious
Feel hyperactive
Have you used any medications to stay awake or to focus in the past? (please list) ____________________________
NEW PATIENT INFORMATION PEDIATRIC & TEEN PEDIATRIC DAYTIME SLEEPINESS SCALE If you are in school, please answer the following questions as honestly as you can by circling one answer only: Question:
4
3
2
1
0
How often do you fall asleep or get drowsy during class periods?
Always
Frequently
Sometimes
Not often
Never
How often do you get sleepy or drowsy while doing homework?
Always
Frequently
Sometimes
Not often
Never
Are you usually alert most of the day?
Never
Not Often
Sometimes
Frequently
Always
How often are you ever tired and grumpy during the day?
Always
Frequently
Sometimes
Not often
Never
How often do you have trouble getting out of bed in the morning?
Always
Frequently
Sometimes
Not often
Never
Very often
Often
Sometimes
Not often
Never
Always
Frequently
Sometimes
Not often
Never
Very often
Often
Sometimes
Not often
Never
How often do you fall back to sleep after being awakened in the morning? How often do you need someone to awaken you in the morning? How often do you think you need more sleep? Total score
MEDICAL HISTORY (CHECK ALL THAT APPLY) ADHD / ADD
Diabetes
Anemia or Iron Deficiency
Headaches
Anxiety / Depression
High Blood Pressure
Asthma / Lung Disease
High Cholesterol or Lipids
Autism spectrum disorder
Mental retardation
Brain Injury or Surgery
Reflux or Ulcer
Cancer
Seizures
Developmental delay
Thyroid Disease
Other medical conditions & Month/Year of diagnoses or symptoms -- Please list: _____________________________________________________________________________________ _____________________________________________________________________________________
NEW PATIENT INFORMATION PEDIATRIC & TEEN SURGICAL HISTORY (INCLUDE MONTH/YEAR) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
MEDICATIONS OR SUPPLEMENTS (INCLUDE DOSE & TIMES PER DAY) _______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
ALLERGIES TO MEDICATIONS
FAMILY HISTORY List immediate family members (include SIBLINGS & BIOLOGICAL RELATIVES) and any Medical Conditions or Chronic Diseases below: Relationship & Age:
Living?
Illness/Disease & Decade of Onset (20’s, 30’s, etc…):
NEW PATIENT INFORMATION PEDIATRIC & TEEN BIRTH / CHILDHOOD HISTORY Was delivery Full Term? Was delivery C-section? Any complications at Birth? Any home monitoring after Birth? Any developmental delay? Any special needs or therapy?
Yes No No No No No
No Yes Yes Yes Yes Yes
If No, how premature _________________________weeks If yes, why? ______________________________________ If Yes, what? _____________________________________ If Yes, what kind? _________________________________ If yes, what kind? _________________________________ If yes, what kind? _________________________________
SOCIAL HISTORY Ethnicity:
Hispanic or Latino American Indian or Alaska Black or African American Native Hawaiian or Other Pacific Islander White or Caucasian Asian
Southeast Asian Other
Which # child in birth order are you in your family? Grade Level:
Special Education Requirements?
Who lives at home with you? List after school activities performed (include # days / week and hrs / day):
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Do you use tobacco?
Yes
Do you drink caffeinated beverages? (Include colas, coffee, iced & hot teas) Have you ever used drugs or alcohol?
No
_________ cigs / cans /day for ______ years
No Yes _________ cups / cans /day If YES, what time is your last caffeinated drink? ______________ No
NEW PATIENT INFORMATION PEDIATRIC & TEEN REVIEW OF SYSTEMS – PLEASE CHECK YES OR NO DO YOU CURRENTLY OR HAVE YOU RECENTLY (LAST 6 MONTHS) EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS?
VISION Seeing double ........................................... Blindness .................................................. Cataracts................................................... Glasses ..................................................... HEARING Deafness ................................................... Hearing aide.............................................. Ringing in the ears .................................... HEAD & NECK Nasal congestion / obstruction .................. Difficulty swallowing .................................. Ear pain / infections................................... Throat pain / infections .............................. Nose bleeds .............................................. Eye pain / infections .................................. Loss of taste.............................................. Loss of voice ............................................. CARDIOVASCULAR Murmur...................................................... Irregular heart rate .................................... Chest pain / tightness at rest..................... Heart racing .............................................. Swollen ankles or legs............................... Palpitations ............................................... PULMONARY Shortness of breath at rest ........................ Shortness of breath w/exercise ................. Coughing................................................... Wheezing .................................................. Tightness in chest ..................................... GASTROINTESTINAL Nausea...................................................... Vomiting .................................................... Abdominal pain ......................................... Diarrhea .................................................... Constipation .............................................. Bright red or black stools........................... Heartburn .................................................. GENITOURINARY Bed wetting ............................................... Puberty reached........................................ Menarche reached ....................................
