Sleep Questionnaire - SSM Cardinal Glennon Children's Medical ...
Sleep Questionnaire - SSM Cardinal Glennon Children's Medical ...
Sleep Questionnaire - SSM Cardinal Glennon Children's Medical ...
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Pediatric <strong>Sleep</strong> and Research Center<strong>SSM</strong> <strong>Cardinal</strong> <strong>Glennon</strong> Children’s <strong>Medical</strong> CenterLabelDate:______________Date of Study:________________Name:__________________________________ DOB:_______________________Address:________________________________ Phone:______________________________________________________ Cell:______________________Parents Name:______________________________ Wk:______________________Referring Doctor:____________________________ Phone#:____________________Family Doctor or Pediatrician:__________________ Phone#:____________________Current <strong>Sleep</strong> Problems:______________________________________________________________________________________________________________________________________________________________________________________________Please Answer YES or NODoes your child:Snore:__________(Loudly:_______ Continuously:_______)Have Noisy Breathing: _______ Change color: _______Have frequent sinus problems: _______ Choke: _______Have awake breathing problems: _______ Turn pale: _______Become congested: _______ Turn blue: _______Have frequent colds: _______ Stop breathing: _______Cough or wheeze at night: _______ Gasp for air: _______Have a tracheostomy: _______ Have GI reflux: _______Receive oxygen therapy: _______ Currently on CPAP: _______Require special treatment (suction, aerosol treatments, ect):_______<strong>Sleep</strong> or Health Problems:Attention problems: _______ Bedwetting: _______Frightening dreams: _______ Leg pains: _______Tooth grinding: _______ Head banging: _______Humming while falling asleep: _______ Body rocking: _______<strong>Sleep</strong>y during the day: _______ Night sweats: _______Difficulty falling asleep: _______ Night waking: _______Difficult to awaken: _______ Hyperactivity: _______Wake during night: _______ Stomach pain: _______Behavioral problems: _______ Night terrors: _______Very emotional or anxious: _______ Overweight: _______<strong>Sleep</strong> at school: _______ Falling asleep at inappropriate times: _______<strong>Sleep</strong> through the night: _______If you answered YES to any above questions, please specify:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please fill out questionnaire and bring with you to your appointment.
LabelPediatric <strong>Sleep</strong> and Research Center<strong>Sleep</strong>ing information:What time does child:Go to sleep: weekdays_______ weekends_______Awaken: weekdays_______ weekends_______Naps: length _______ # per day _______Does the Child:<strong>Sleep</strong> in their own room: _________ <strong>Sleep</strong> with parents: ________Share a room with siblings _________ Share a bed with siblings: ________<strong>Sleep</strong> in bed or crib: _________ <strong>Sleep</strong> with lights on: ________Listen to music to fall asleep: _________ Watch tv to fall asleep: ________<strong>Medical</strong> HistoryHeight:________ Weight:_________ (approximate if not known)Previous Hospitalizations and diagnostic testing (year and diagnosis):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tonsil and Adenoid Removal (when and where):________________________________Previous surgeries:_______________________________________________________________________________________________________________________________Current Medications: (Drug and Dosage)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family History:<strong>Sleep</strong> Disorders (what & whom):_____________________________________________________________________________________________________________Asthma or other lung disease (what & whom):___________________________________________________________________________________________________Other: __________________________________________________________________________________________________________________________________Allergies: (medication/latex)______________________________________________________________Please fill out questionnaire and bring with you to your appointment.
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