Pediatric Patient Form Pediatric Questionnaire "*" indicates required fields PATIENT DEMOGRAPHICSBring the printed materials for office visit or you could fax it to 989-793-7113 or 989-792-1792 Who is the Physician that referred you to us?* Does your child see any other healthcare providers?* Yes No Do you want this report sent to another Physician? Yes No Please list any sleep disorders suspected by your provider in your child:PERSONAL INFORMATIONName* First Middle Initial Last Sex Male Female Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age (in years)Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Weight*Height*Feet*Inches*BMIParent or Guardian InformationName of Person Answering Questions:* Relationship to Child: Your Day Phone Number:*Evening Phone Number:Your Email:* Relative's Number in case we cannot reach you:Relative's Name: Please answer the questions on the following pages regarding the behavior of your child during sleep and wakefulness. The questions apply to how your child acts in general, not necessarily during the past few days since these may not have been typical if your child has not been well. If you are not sure how to answer any question, please feel free to ask your husband or wife, child, or physician for help. You should mark the correct response or print your answers neatly in the space provided. When you see the word “usually” it means “more than half the time” or “on more than half the nights.”General Information About Your Child:Nighttime and Sleep BehaviorWhile Sleeping, Does Your Child:Ever snore?* Yes No I Don't Know Always snore?* Yes No I Don't Know Have trouble breathing, or struggle to breathe?* Yes No I Don't Know Have You Ever:Seen your child stop breathing during the night?* Yes No I Don't Know Been concerned about your child's breathing during sleep?* Yes No I Don't Know Had to shake your child to get them to breathe, or wake up and breathe?* Yes No I Don't Know Seen Your Child Wake Up With a Snorting Sound?* Yes No I Don't Know Does Your Child:Have restless sleep?* Yes No I Don't Know Have growing pains (unexplained leg pains)?* Yes No I Don't Know Have growing pains that are worse in bed?* Yes No I Don't Know While Your Child Sleeps, Have You Seen:Brief kicks from one leg or both legs?* Yes No I Don't Know At Night, Does Your Child Usually:Become sweaty, or do their pajamas usually become wet with perspiration?* Yes No I Don't Know Get out of bed (for any reason)?* Yes No I Don't Know Get out of bed to urinate?* Yes No I Don't Know If So, How Many Times Each Night, on Average?Does your child usually sleep with their mouth open?* Yes No I Don't Know Is your child's nose usually congested or stuffed at night?* Yes No I Don't Know Do any allergies affect your child's ability to breathe through their nose?* Yes No I Don't Know Does Your Child:Tend to breathe through their mouth during the day?* Yes No I Don't Know Have a dry mouth upon waking up in the morning?* Yes No I Don't Know Get a burning feeling in the throat at night?* Yes No I Don't Know Grind their teeth at night?* Yes No I Don't Know Occasionally wet the bed?* Yes No I Don't Know Has your child ever walked during sleep (Sleep Walking)?* Yes No I Don't Know Have you ever heard your child talk during sleep (Sleep Talking)?* Yes No I Don't Know Does your child have nightmares once a week or more on average?* Yes No I Don't Know Has your child ever woken up screaming during the night?* Yes No I Don't Know Has your child ever been moving or behaving, at night, in a way that made you think your child was neither completely awake nor asleep?* Yes No I Don't Know If so, please describe what happened?Does your child have difficulty falling asleep at night?* Yes No I Don't Know How long, in minutes, does it take your child to fall asleep at night? (A guess is O.K.)*At bedtime does your child usually have difficult routines or rituals, argue a lot, or otherwise act out?* Yes No I Don't Know How many times does your child wake up from sleep on a typical night?*How long, in minutes, does it take for your child to fall back to sleep after waking up, on a typical night?*Does Your Child:Bang their head or rock their body when going to sleep?* Yes No I Don't Know Wake up more than twice a night on average?* Yes No I Don't Know Have trouble falling back asleep if they wake up at night?* Yes No I Don't Know Wake up early in the morning and have difficulty going back to sleep?* Yes No I Don't Know Does the time at which your child goes to bed change a lot from day to day?* Yes No I Don't Know Does the time at which your child gets up from bed change a lot from day to day?* Yes No I Don't Know What Time Does Your Child Usually:Go to bed during the week?* Go to bed on the weekend or vacation?* Get out of bed on weekday mornings?* Get out of bed on weekend or vacation mornings?* Daytime Behavior And Other Possible Problems:Does Your Child:Wake up feeling unrefreshed in the morning?* Yes No I Don't Know Have a problem with sleepiness during the day?* Yes No I Don't Know Complain that they feel sleepy during the day?* Yes No I Don't Know Has a teacher or other supervisor commented that your child appears sleepy during the day?* Yes No I Don't Know Does your child usually take a nap during the day?* Yes No I Don't Know Is it hard to wake your child up in the morning?* Yes No I Don't Know Does your child get a headache at least once a month, on average?* Yes No I Don't Know Does your child still have tonsils?* Yes No I Don't Know If not, when were the tonsils or adenoids removed: MM slash DD slash YYYY Has Your Child Ever:Become suddenly weak with muscles in the legs, or anywhere else, after laughing or being suprised by something?* Yes No I Don't Know Felt unable to move for a short period, in bed, though awake and able to look around (Sleep Paralysis)?* Yes No I Don't Know Has your child felt an irresistible urge to take a nap at times, forcing them to stop what they are doing in order to sleep?* Yes No I Don't Know Has your child ever sensed that they were dreaming (seeing images or hearing sounds) while still awake?* Yes No I Don't Know Does your child drink caffeinated beverages on a typical day (cola, tea, coffee)?* Yes No I Don't Know If so, how many cups per day?Does your child use any recreational drugs?* Yes No I Don't Know Is your child overweight?* Yes No I Don't Know Has your child ever taken Ritalin (Methylphenidate) for behavioral problems?* Yes No I Don't Know Has a health professional ever said that your child has attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD)?* Yes No I Don't Know Additional InformationIf your child has long-term medical problems, please list the three you think are most significant:Does your child have Asthma/Allergies?* Yes No I Don't Know Does your child have ADHD?* Yes No I Don't Know Does your child have Heart Disease?* Yes No I Don't Know Does your child have behavioral issues?* Yes No I Don't Know Please Specify: Does your child have other medical issues?* Yes No I Don't Know Please Specify: Please list any medications your child currently takes:Please list any medications your child has taken in the past if the purpose of the medication was to improve their behavior, attention, or sleep. Please list the medication's name, dose, how often it was taken, the dates it was taken, and what was the effect:INSURANCE INFORMATIONPrimary Insurance Name* Policy# Secondary Insurance Name Policy# (Complete only if you are not the Insurance Policy Holder)Policy Holder Name First Middle Initial Last Relationship Policy Holder’s Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Holder’s Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip AUTHORIZATION I authorize the release of any medical information necessary to process my insurance claim, and authorize payment of medical benefits to the Facility and providers for services rendered. I am aware that payment of insurance copay/deductible is the patient’s responsibility. If necessary, I also authorize release of medical information to durable medical equipment providers and referring/primary care providers involved in my care. I authorize the use of audio and video monitoring as part of my sleep study. I understand that the copay / deductible is my responsibility. I am also aware that the Sound aSleep Sleep Diagnostic Lab facility is owned and operated by Narendra R. Kumar, M.D., P.C.* I authorize and agree by checking this box and typing my name below Your Name* Date* Check the box belowCommentsThis field is for validation purposes and should be left unchanged.
