Pediatric Sleep Questionnaire Form

39755 Date St., Ste. 101
Murrieta, CA 92563
951 698 6629
www.completesleepsolutions.com

1. Pediatric Sleep Questionnaire



Please answer the following questions as completely as possible. Space at the end of the questionnaire is for any further questions/comments/observations you think important.
If a particular question does not apply to your child please write NA.

If the question applies, but you do not know the answer, please write DK



2. MEDICATIONS
Name Dose How Often Reason



3. MEDICAL & PSYCHOLOGICAL HISTORY
High Blood Pressure
Asthma
Seizures
Kidney Disease
Thyroid Disease
Cerebral Palsy
Down Syndrome
Panic/Anxiety
Heart Abnormality
Diabetes
Head Trauma
Meningitis
Intestinal Abnormality
Congenital Defects
ADHD
Depression
4. SLEEP SCHEDULE / HYGIENE / ENVIRONMENT



10. Does your child

















5. EXCESSIVE DAYTIME SLEEPINESS





Reading :
Watching TV :
Conversations :
Meals :
School :


6. SLEEP BREATHING


Choking
Episodes of Stopping Breathing
Struggling to Breath?
Wheezing
Awakenings



7. MOVEMENT







8. PARASOMNIAS
















9. FAMILY SLEEP HISTORY




10. OPTIONAL

To better serve this community with information on sleep disorders and their treatments we would like to know how you heard about us: (Please Circle)

Thank you for your cooperation filling out this questionnaire. Please be assured that this information is confidential.

Registration
(Please Print)

Talha Memon M.D
39755 Date St Ste. 101
Murrieta, CA 92563

Tel : (951) 698 - 6629
Fax : (951) 698 - 8732



Acknowledgement of Receipt of Notice of Privacy Practices


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