PEDIATRIC INTAKE FORM

ANCHORAGE SLEEP CENTER PEDIATRIC INTAKE
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Email
example@example.com
Primary Care Provider
Specialty Care Provider(s)
What are the sleep related concerns for your child?
Please fill in where applicable.
Day Care: Days of week and hours of attendance:
Public School:      Days of week and hours of attendance: Current Grade:   Academic Performance:    IEP Support?     Behavioral issues in school?

Extracurricular activities:      Afterschool activities:    Days of Week and hours of attendance:

Scheduled evening activities:    Days of Week and hours of attendance:

Employment:    Current employment (if applicable):     Hours of work:
CURRENT ACTIVE MEDICAL CONSIDTIONS (medical or psychiatric conditions for which patient is currently being actively evaluated or treated
PAST MEDICAL HISTORY (i.e. medical and psychiatric conditions currently being treated, hospitalizations, serious accidents or illnesses)
SURGICAL HISTORY
BIRTH HISTORY:
Age of mother at time of birth
Number of pregnancies prior to pregnancy with patient
Number of children delivered prior to patient
Complications with pregnancy with patient (i.e. pre-term delivery; hypertension during pregnancy, gestational diabetes, pre-eclampsia; eclampsia):
Complications during infancy or early childhood:
CURRENT MEDICATIONS
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Name of drug Dose(strength & #pills/day)
Allergies?

YesNo
If "Yes" so please list
SOCIAL HISTORY
BIRTH PLACE
City
State
CURRENT RESIDENCE: Address
City
State
Zip
Care Giver/Parent #1: Relationship to child
Employed

YesNo
Occupation
Shift Work
Address
City
State
Zip
Giver/Parent #2: Relationship to child
Employed

YesNo
Occupation
Shift Work
Address
City
State
Zip
Family members in household
Does your child sleep regularly in another household? If so, how many nights a month?
Does your child sleep in their own bedroom? If not, who else sleeps in the bedroom
Check if does NOT apply:

Tobacco UseCaffeine UseAlcohol UseCannabis UseIllicit Drug Use
GENERAL HEALTH
Medical Diagnosis (Check all which apply)

Failure to thriveUnderweightObesity/Overweight
Symptoms (Check all which apply)

Excessive weight gainUnusual weight lossNight sweats
Comments:
Sleep
Medical Diagnosis (Check all which apply)

Obstructive sleep apneaRestless Legs SyndromePeriodic Limb Movement DisorderNocturnal seizures
Symptoms (Check all which apply)

Sleep talkingSleep walkingNight terrorsActing out dreamsHallucinations at nightSleep eatingUnusual behaviors at night
Comments:
Eyes
Medical Diagnosis (Check all which apply)

GlaucomaRetinal disordersEye surgeryTear duct surgery
Comments:
HEENT
Medical Diagnosis (Check all which apply)

Nasal fracture / Facial traumaNasal or sinus surgeryAdenotonsillectomyWisdom teeth extractionOrthodontic surgery
Symptoms (Check all which apply)

Nasal fracture / Facial traumaNasal or sinus surgeryAdenotonsillectomyWisdom teeth extractionOrthodontic surgery
Comments:
Cardiology
Medical Diagnosis (Check all which apply)

HypertensionHeart valve disorderArrhythmiasHeart FailureHeart condition (not listed)
Symptoms (Check all which apply)

PalpitationsShortness of breathSwelling of ankles
Comments:
Pulmonary
Medical Diagnosis (Check all which apply)

AsthmaChronic lung conditionsChest trauma / rib fracturesChest / Thoracic SurgeryLung condition (not listed)
Symptoms (Check all which apply)

SnoringSnore arousalsAwakening with gaspingNighttime coughNighttime shortness of breathNighttime wheezingObserved pauses in breathingHistory of low oxygen levels
Comments:
GI
Medical Diagnosis (Check all which apply)

GERD / RefluxPeptic Ulcer Disease
Symptoms (Check all which apply)

Nighttime heartburn or refluxNighttime vomitingNighttime abdominal pain
Comments:
Genitourinary
Medical Diagnosis (Check all which apply)

Chronic kidney disordersEnuresis / bedwetting
Symptoms (Check all which apply)

Frequent nighttime urinationBedwetting
Comments:
Endocrine
Medical Diagnosis (Check all which apply)

HypothyroidismHyperthyroidismThyroid nodulesHigh cholesterolVitamin D deficiencyIron deficiency
Comments:
Neurologic
Medical Diagnosis (Check all which apply)

Seizures/ EpilepsyConcussion/ Traumatic Brain injuryChronic headachesMigraine HeadachesAutistic Spectrum Disorder
Symptoms (Check all which apply)

Morning headachesBedwettingRestless legs in the eveningsChanges in memoryChanges in concentration
Comments:
Psychiatric
Medical Diagnosis (Check all which apply)

ADHDDepressionAnxiety DisordersBi-Polar DisorderOppositional Defiant DisorderAutistic Spectrum Disorder
Symptoms (Check all which apply)

Changes in moodUnusual IrritabilityLabile emotionally
Comments:
Hematologic
Medical Diagnosis (Check all which apply)

AnemiaBlood clots (legs or lungs)
Comments:
Musculoskeletal
Medical Diagnosis (Check all which apply)

Connective Tissue disorderSignificant musculoskeletal trauma
Symptoms (Check all which apply)

Chronic musculoskeletal painNighttime leg cramps
Comments:
Allergic/Immunologic
Medical Diagnosis (Check all which apply)

Allergic rhinitisAsthmaHives (urticaria)Food allergies
Symptoms (Check all which apply)

Nighttime wheezingNight cough
Comments:
Please fill in where applicable.
Questions 1-9 refer to child's sleep during the last 1 month on School Nights:

SCHOOL NIGHTS ARE CONSIDERED:

MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY

1. What time does your child go to bed at night? blanks PM/AM
2. How much does your child’s bedtime and wake up time change from day to day for school nights
Less than 15 mins. 15 to 30 mins. 30 to 60 mins. More than 60mins
3. How often does your child have difficulty falling asleep at night out of 5 nights? Never Not during the past month Less than once a week 1-2 times a week 3-4 times a week 5 or more times a week
3A. How much time does it usually take your child to fall asleep after going to bed? Hrs. Mins.
3B. What is the longest time it has taken your child to fall asleep after being put to bed? Hrs. Mins.
4. How often do night wakings occur? Once Twice 3 times or more None
4A. How often do night wakings occur? Never Not during the past month Less than once a week 1-2 times a week 3-4 times a week 5 or more times a week
4B. How much time does it usually take her/him to fall back to sleep after waking in the night? Hrs. Mins.
5. On average, how many hours does your child sleep on school nights? Hrs.
6. What time does your child wake up on school mornings? AM/PM
7. What time does your child’s school start? AM/PM
8. On how many school mornings does your child: Please choose one number.
a. Wake up on her/his own?

012345
b. Use an alarm to wake up?

012345
c. Use an alarm to wake up?

012345
d. Need to be awakened several times before getting out of bed?

012345
9. How often does your child have difficulty waking up in the morning?

1-2 days2-3 days4-5 daysNone
10. Does your child nap?

YesNo
10A. How often does your child nap?

Once a dayMore than once a dayNever
10B. How many days does your child nap during the weekday?

12345
10C. If your child naps on the weekday, how long is a typical nap? Hrs. Mins.
10D. What time(s) does your child nap? PM/AM TO PM/AM

Questions 11-18 refer to child's sleep during the last 1 month on Weekend/Vacation Nights:

Weekend Nights are considered:

FRIDAY	SATURDAY

11. What time does your child go to bed at night? PM/AM
12. How often does your child have difficulty falling asleep at night?

NeverNot during the past monthOne NightBoth Nights
12A. How much time does it usually take your child to fall asleep after going to bed? Hrs. Min.
12B. What is the longest time it has taken your child to fall asleep after being put to bed?Hrs. Min.
13.How many times per night does your child wake up in the middle of the night and take 10 or more minutes to fallback to sleep?

OnceTwice3 times or moreNone
13A. How often does your child have night wakings?

NeverNot during the past monthOne NightBoth Nights
13B. How much time does it usually take her/him to fall back to sleep after waking in the night? Hrs. Mins
14. What time does your child wake up in the morning?PM/AM
15. Do you wake your child in the mornings?

NeverSometimesAlways
16. How often does your child have difficulty waking up?

NeverNot during the past monthOne NightBoth Nights
17. Does your child nap during the weekend?

YesNo
17A. How often does your child nap?

Once a dayMore than once a dayNever
17B. How many days does your child nap?

1 dayBoth daysNone
17C. If your child naps, how long is a typical nap? Hrs. Mins.
17D. What time(s) does your child nap? PM/AM TO PM/AM
18. On average, how many hours does your child sleep on weekend nights?
Hrs.
General Sleep Questions
19. If your child set his/her own schedule, which would she/he prefer?

Go to bed early and wake up earlyGo to bed late and wake up lateNo preferenceNo preference
20. How much sleep do you think your child needs? Hrs. Mins.
21. Which of the following does your child have in her/his bedroom? (please check all that apply):

TV/DVDComputer/TabletVideo Game SystemCellular Phone
22. Has your child ever taken over-the-counter or prescription medications at bedtime to help her/him calm down in the evening and/or fall asleep?

YesNo
If yes, please list the medications and dose:
23. Does your child drink caffeinated beverages (for example, colas, iced tea, Mountain Dew, energy drinks, Sunkist, chocolate milk) or eat foods that contain caffeine (for example, chocolate)?

YesNo
If yes, please check one:

NeverNot during the past monthLess than once a week1-2 times a week3-4 times a week5 or more times a week
Below is a list of questions about various sleep problems. For each question please think about the last month. Please answer all items the best you can, even if some of these questions do not apply to your child.
24. How often is there a regular bedtime routine in your home?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
25. How often does your child share a bedroom with another family member?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
26. How often does your child sleep in a caretaker’s bed?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
27. How often does your child resist going to bed?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
28. How often is bedtime and the hour leading up to it a stressful time?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
29. After bedtime, how often does your child call you back to the bedroom more than 2 times?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
30. Does your child have uncomfortable feelings in the legs or arms (occurring at bed time or when sitting for a long time) that are relieved by movement or rubbing? Please check one:

YesNo
31. How often do you observe your child while she/he sleeps?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
32. How often does your child snore?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
32a. If your child snores, it can be heard…. Please check one:

Only in her/his bedroomOne room awayTwo or more rooms away on the same floorThroughout the entire house
33. While your child is sleeping, does s/he have any breathing problems? Please check all that apply:

Struggles to breathGaspsHolds her/his breathStops breathing for short periods of time
34. If yes, how often do these breathing problems occur?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
35. How often does your child grind her/his teeth while sleeping?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
36. How often is your child a restless sleeper?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
37. How often does your child wet her/his bed at night?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
37A. If your child wets the bed has s/he ever been completely dry for more than one week?

YesNo
38. How often does your child report having nightmares or frightening dreams?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
39. How often does your child wake up during the night screaming, agitated or confused?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
39A. While sleepwalking has s/he ever: Please check all that apply:

Been at risk of injuryBeen injuredAttempted to leave the bedroomAttempted to leave the home
39B. If yes, does s/he remember waking up the next morning?

YesNo
40. How often does your child sleep walk?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
40A. While sleepwalking has s/he ever: Please check all that apply:

Been at risk of injuryBeen injuredAttempted to leave the bedroomAttempted to leave the home
41. Does your child have repetitive movements during sleep? For example (please check all that apply):

Leg jerksHead bangingLip smackingOther (please specify)
42. How often does your child fall asleep suddenly at unexpected times?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
43. How often does your child report having very real dreams that there is a person or animal in her/his room?

NeverNot during the past monthLess than once a week1 or 2 times once a week3 or 4 times once a week5 or more times once a week
44. How often has your child experienced sudden muscle weakness including weak knees/buckling of the knees and sagging of the jaw during emotions like laughing, happiness, or anger?

Less than 1/month1-3 times/ month1-2 times/ monthAlmost always
Please rate your child’s chances of falling asleep or dozing in each of the situations listed below. Think about a typical day: Please check one:
A. Sitting and Reading

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
B. Watching TV

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
C. Sitting quietly in public (in movie/ school)

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
D. Riding in a car or on a bus

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
E. Lying down to rest in the afternoon

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
F. Lying down to rest in the afternoon

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
G. Lying down to rest in the afternoon

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
H. While doing homework or reading

Would never dozeSlight chance of dozingModerate chance of dozingHigh chance of dozing
How concerned are you about your child’s sleep problem? Please pick a number on the scale below.
Not Concerned

0123
Moderately Concerned

4567
Extremely Concerned

8910
Do you have additional comments about your child's sleep or health?
Signature
Should be Empty:

ANCHORAGE SLEEP CENTER PEDIATRIC INTAKE

BIRTH HISTORY:

CURRENT MEDICATIONS

SOCIAL HISTORY

GENERAL HEALTH

Sleep

Eyes

HEENT

Cardiology

Pulmonary

GI

Genitourinary

Endocrine

Neurologic

Psychiatric

Hematologic

Musculoskeletal

Allergic/Immunologic

Questions 1-9 refer to child's sleep during the last 1 month on School Nights:

General Sleep Questions