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Sleep Disorders Assessment
Michael
2023-04-26T08:53:18-05:00
Sleep Disorders Assessment
What is your/your child's primary sleep concern?
Patient's Name
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Last
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Your child's sleep during the past four weeks...
1. While sleeping, does your child snore?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
2. While sleeping, does your child have "heavy" or loud breathing?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
3. While sleeping, does your child have trouble breathing, or struggling to breathe?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
4. Does your child snort and/or gasp during sleep?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
5. Have you seen your child stop breathing during the night?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
6. Does your child tend to breathe through the mouth during the day?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
7. Does your child have a dry mouth or sore throat on waking up in the morning?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
8. Does your child go to bed at the same time at night?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
9. Does your child fall asleep alone in his/her own bed?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
10. Does your child fall asleep within 20 minutes after going to bed?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
11. Does your child sleep the right amount?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
12. Does your child sleep the same amount each day?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
13. Does your child fall asleep in parent's or sibling's bed?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
14. Does your child struggle at bedtime (cries, refuses to stay in bed, etc.)?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
15. Does your child need a parent in the room to fall asleep?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
16. Is your child afraid of sleeping alone?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
17. Is your child afraid of sleeping in the dark?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
18. Does your child have trouble sleeping away from home (visiting relatives, vacation)?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
19. Does your child move to someone else's bed during the night (parent, sibling, etc.)?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
20. Does your child awaken once during the night?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
21. Does your child awaken more than once during the night?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
22. Does your child talk during sleep?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
23. Is your child restless and move a lot during sleep?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
24. Does your child sleepwalk during the night?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
25. Does your child wet the bed at night?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
26. Does your child grind his/her teeth during sleep (your dentist may have told you this)?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
27. Does your child awaken alarmed by a frightening dream?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's sleep during the past four weeks...
28. Does your child awaken during the night screaming, sweating, and inconsolable?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
29. Does your child wake up by him/herself in the morning?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
30. Does your child wake up in a negative mood?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
31. Does your child take a long time to become alert in the morning?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
32. Does your child seem tired/unrefreshed in the morning?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
33. Does your child wake up with headaches in the morning?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
34. Does your child have problems with sleepiness during the day?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
35. Has a teacher/supervisor commented that your child appears sleepy during the day?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
36. Does your child seem NOT to listen when spoken to directly?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
37. Does your child have difficulty organizing tasks and activities?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
38. Is your child easily distracted by extraneous stimuli?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
39. Does your child fidget with hands or feet, or squirm in seat?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
40. Does your child seem "on the go" or often act as if "driven by a motor"?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
41. Does your child interrupt or intrude on others (e.g., butt into conversations or games)?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
42. Does your child have "sleep attacks" or cataplexy (episodes of sudden weakness)?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's daytime behavior during the past four weeks...
43. Does your child feel paralyzed when trying to wake up for fall asleep?
Yes
No
Don't Know
If yes, # of days per week:
select
1
2
3
4
5
6
7
Your child's overall health...
44. Has your child grown at a less than normal rate at any time since birth?
Yes
No
Don't Know
Your child's overall health...
45. Does your child take any chronic medications (for longer than 4 weeks)?
Yes
No
Don't Know
List
Medication
Reason
Dose
# Doses per Day
Add
Remove
"Usually" means more than half the time..
46a. How much total sleep in a 24 hour periodic does your child get on weekdays?
select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
46b. How much total sleep in a 24 hour periodic does your child get on weekends or vacation?
select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
"Usually" means more than half the time..
47. How long does it usually take your child to fall asleep at night (minutes)?
select
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
120+
"Usually" means more than half the time..
48a. What time does your child usually go to bed on weekdays?
Hours
:
Minutes
AM
PM
AM/PM
What time does your child usually wake up on weekdays?
Hours
:
Minutes
AM
PM
AM/PM
48b. What time does your child usually go to bed on weekends or vacation??
Hours
:
Minutes
AM
PM
AM/PM
What time does your child usually wake up on weekends or vacation?
Hours
:
Minutes
AM
PM
AM/PM
49b. How many hours does your child usually nap during the day on weekends or vacation?
select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Specifically when your child was an infant...
50. Right after your child was born, did they require any of the following: (check all that apply)
Apnea Monitor
Caffeine
Oxygen
Pulse Oximeter
None of these
Other
please describe
Indicate whether your child has had any of the procedures or diagnoses listed...
51. Has your child ever had surgery to remove tonsils and/or adenoids?
Yes
No
Indicate whether your child has had any of the procedures or diagnoses listed...
52. Has your child ever been treated at home with Continuous, Bi-level, or Variable Positive Airway Procedure (CPAP, Bi-PAP or VPAP)?
This machine helps keep the airway open using a mask that is placed over the nose and or mouth.
Yes
No
Indicate whether your child has had any of the procedures or diagnoses listed...
53. Has your child ever had polysomnography (an overnight sleep study) at another facility?
Yes
No
If yes, at what facility?
Indicate whether your child has had any of the procedures or diagnoses listed...
54. Has a provider ever diagnosed your child with sleep apnea or sleep disordered breathing?
Yes
No
Pertains to household and immediate family members...
55. Does anyone who lives at home work variable shifts such as night shift?
Yes
No
Pertains to household and immediate family members...
56. Has a provider ever diagnosed an immediate family member with sleep disordered breathing or sleep apnea?
Yes
No
Which family member(s)? (check all that apply)
Mother
Father
Brother
Sister
Grandmother
Grandfather
Other
Specifically about school (preschool/daycare) and attendance...
57. Current grade in school:
select
daycare
preschool
pre-K
1
2
3
4
5
6
7
8
9
10
11
12
58. How many absences this year (estimated):
select
0
1
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38
39
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41
42
43
44
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46
47
48
49
50+
Specifically about school (preschool/daycare) and attendance...
59. How many tardies this year:
select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
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49
50+
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