Printer-friendly version sleep medicine medical history name/date today’s date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 child’s first and last name: * child’s nickname (if applicable) child’s birthdate: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 child’s date of birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 child’s gender: - None -MaleFemale your name: your relationship to the child: contact information street address city state zip code telephone number (best phone number) alternate telephone number (secondary phone number) email address general information what sleep related concerns do you have about your child? * * when were you first concerned about these issues? have you previously sought assistance for these concerns? medical history please describe any past or present medical and psychological issues with this child does your child have any allergies to medications? If yes, please include name and reaction if known. has your child had any surgeries or procedures? if yes, please include approximate dates. has your child had any hospitalizations? if yes, please include approximate dates. current medications Please list all medications your child takes including dosage and frequency. birth history select one: - None -full termpre-term post-term (late) was your child breeched? - None -yesno is your child a twin or triplet? - None -yesno how was your child delivered? - None -vaginal c-section forceps vacuum delivery please describe any complications had during pregnancy, labor and delivery. other diseases: explain. social history who lives at home with this child? please include ages and relationship. if shared custody or shared living arrangements please describe: birth parent’s marital status - None -marrieddivorced separatednever married if divorced or separated please include dates: if either birth parent has remarried please include dates for their current marriage: Please indicate who the child is with during these times (parent, daycare, school, other) Weekdays before 8am - None -parentdaycareschoolother please describe weekdays 8:00 am - 5:00 pm - None -parentdaycareschoolother please decribe weekdays after 5:00 pm - None -parentdaycareschoolother please describe weekends before 8am - None -parentdaycareschoolother please describe weekends 8:00 am - 5:00 pm - None -parentdaycareschoolother please describe weekends after 5:00 pm - None -parentdaycareschoolother please decribe school and activities child’s grade child’s current school: school city: current grades in school are mostly: - None -AB C D E F what extracurricular activities is your child involved in? (ex: dance, scouts, sports etc…) what other hobbies or interests does your child have? is your child on an individual education plan (IEP)? - None -yesno How many hours does your child spend each day with: TV - None -0-2 hours2-4 hours4+ hours computer/phone/tablet - None -0-2 hours2-4 hours4+ hours video games - None -0-2 hours2-4 hours4+ hours does your child drive? - None -yesno if yes, has your child had driving violations or car accidents? please explain. caffeine consumption: please estimate how many cups of the following the child has per day. - None -01-22+ sleep environment where does your child sleep? choose one - None -own room bedroom with sibling parent’s bedroom other if other, please explain what does your child sleep on? - None -cribtoddler bed twin bed full bed bunk bedmattress on the floorfloorwaterbed sofa/couchfuton queen/king other: explain. other option what objects are in your child’s bedroom? check all that apply. TV computeralarm clock audio speakers video game player (i.e., Xbox, Nintendo, PlayStation)fan night lightphonetablet who usually puts your child to bed? check all that apply. mom father self grandparentsitter other: explain other person option what is their usual bedtime during the week? what time do they normally wake up during the week? what is their usual bedtime on the weekend? what time do they normally wake up on the weekend? how long does it usually take your child to fall asleep? how many times does your child usually get up during the night? does your child need a special object to sleep with? how often does your child usually nap during the day? how long? does your child snore? check one. - None -never occasionally sometimes frequentlyalways if yes, how would you describe your child’s snoring? check one. - None -soft moderately loudloud very loud does it scare you? - None -yesno does your child do any of the following at night: check all that apply. sleepwalksleep talksleep terrorsfrequent bad dreams/nightmareswet the bedtrouble falling asleeptrouble staying asleepgrinds teethrestless/moves a lotcomplains of pain does your child have trouble with: check all that apply. daytime sleepinessunrefreshing sleepheadachesdry mouth before bed activities: check all that apply. brush teethbathe/showersnackTVbookmusicother: explain review of systems—check all that currently apply to your child. glasses or contact lensesunusual vision or eye issueshearing aiddental problemsgum problemsbraces or palate expandersorthodontic problemsfrequent sinus problemsnasal congestion problemsallergiesfrequent dry mouthfrequent headachesfrequent sore throatsrecurrent strep infectionsswallowing problemsspeech problemshoarseness or voice problemsfainting spellsunusual dizzinessheart murmurspalpitationstires easily with exertionunusual coughingwheezingchest painsheart burn or acid refluxshortness of breathrecurrent croup or stridorrecurrent pneumoniarecurrent respiratory infectionsunusual infectionsstomach achesnausea or vomitingdiarrheaconstipationchange in appetiterecent unexplained weight loss or weight gainfood allergies or intoleranceincontinence during the daypain with urinationrashesanxiety or stressunusual fearfulnessdepression or feeling sad or “blue”nail bitingthumb suckingbad temper or aggressivenessbehavior problems at school or homebad attitudehyperactiveshort attention spandevelopment delayseasy bruising back pains or problemsbone or join problems
