SoFHA
Patient Forms

Pediatric Patient Paperwork

Description:

The SoFHA Sleep Center new pediatric patient paperwork.

Code:

9.002

Issued:

06/11/2019

Revision:

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

Name First, MI, Last

Date of Birth

Address Line 1

Address Line 2Optional

City

State

Zip Code

HeightOptional

WeightOptional

Neck SizeOptional

Gender

Home Phone

Cell Number

Work Number

EmployerOptional

OccupationOptional

Insured Information

Relationship to Insured

Insured's Name If not patient

Insured's Social Security

Insured's Date of Birth

Physician Information

Pediatrician

Phone

Specialty

Referring Physician

Phone

Specialty

Reason For Visit

What are your major concerns regarding your child's sleep?

How long has your child had this problem?

Months

Years

Sleep Schedule

Weekday

Bedtime

Wake Time

# of naps taken per day

Length of naps

Weekend

Bedtime

Wake Time

# of naps taken per day

Length of naps

Time it takes to go to sleep

Times per night your child wakes up

Does he/she fall back to sleep easily?

What wakes your child from their sleep?

Pain

Bladder Full

Noise

Light

Pets

Temperature

Mattress

Unknown

Other

Does your child have a TV, radio, iPod, cell phone, or other electronic device at night?

Yes

Epworth Sleepiness Scale

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

Sitting and Reading

None

Slight

Moderate

High

Watching TV

None

Slight

Moderate

High

Sitting inactive in a public place (Theater or Classroom)

None

Slight

Moderate

High

As a passenger in a car for an hour without a break

None

Slight

Moderate

High

Lying down to rest in the afternoon

None

Slight

Moderate

High

Sitting and talking to someone

None

Slight

Moderate

High

Sitting quietly after a lunch

None

Slight

Moderate

High

Doing homework, taking a test, or playing

None

Slight

Moderate

High

Medical History

Sleep Apnea

Snoring

Gasping and Choking

Cessation of Breathing

Oropharyngeal Crowding

Excessive Daytime Sleepiness

Daytime Sleepiness

Tired After Awaking

Fatigue

Restless Leg Syndrome

Nighttime Urination

Other

General

Weight Gain

Weight Loss

Diabetes

Morning Headaches

Depression/Anxiety

Night Sweats

Cardiac

Hypertension

Heart Abnormality

Cardiac Arrhythmias

Heart Murmur

Other

Neurological

Headaches

Developmental Delay

Cerebral Palsy

Narcolepsy

Seizures

Motor Development

Other

Safety

Sleepy While Active

Behavior Problems

Failing Job Performance

School Performance

Higher Risk of Accidents

Memory Loss

Dementia

Alzheimer's Disease

Difficulty Concentrating

Interferes with ADL's

Past Surgical History

Adenoids Removed

Tonsils Removed

Sinuses

Cardiac Surgery

Uvulopalatopharyngoplasty

Jaw Surgery

Weight Loss Surgery

Cleft Lip

Ear Tubes

Nasal Surgery

Other

Sleep Symptoms

Cannot Fall Asleep

Cannot Stay Asleep

Wakeup Too Early

Bad Dream

Awake Confused

Fall Asleep Anytime

Awake Panic / Frightened

Wet Bed

No Good Sleep

Other

Social History

Alcohol Use

Tobacco Use

Caffeine use within 2 hours of bedtime

Cups of caffeinated beverages per day

PAP Treatment

Has your child ever been diagnosed with sleep apnea?

Yes

Is your child currently using CPAP/BiPAP?

Yes

Does your child wake up feeling rested?

Yes

Family History

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

Sleep Apnea Relative(s)

Restless Leg Syndrome Relative(s)

Narcolepsy Relative(s)

Sleepwalking Relative(s)

Current Medications

Pharmacy Name and Location

Current Medications

Is your child currently using or have used oxygen at home?

Yes

DME Company

Allergies

Environmental or Medical

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.

Relationship to Patient

Parent/Guardian Signature