SoFHA
Patient Forms

Pediatric Patient Paperwork


Description:

The SoFHA Sleep Center new pediatric patient paperwork.


Code:

9.002

Issued:

06/11/2019

Revision:

1

Revised:

N/A

It is important that you fill out this sleep questionnaire completely and as accurately as possible. Please answer each question. The questionnaire is a broad-based screening tool that will assist our staff and your treating sleep physician to provide excellent care to your child. It may be helpful to consult with a family member when answering these questions. All information contained in this questionnaire will become a part of your child's medical record and will be confidential.

Directions to Our Office

Notice of Nondiscrimination

Interpreter Services


Patient Information



















Insured Information







Physician Information









Reason For Visit


How long has your child had this problem?





Sleep Schedule

Weekday








Weekend












What wakes your child from their sleep?


Epworth Sleepiness Scale

Please estimate your child's risk of falling asleep in the following situations.


Medical History


Sleep Symptoms


Social History







PAP Treatment


Family History

Which blood relatives have been diagnosed with any of the following:







Current Medications





Allergies



Signature

By typing your name in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.