Sleep Questionnaire - SSM Cardinal Glennon Children's Medical ...
Sleep Questionnaire - SSM Cardinal Glennon Children's Medical ...
Sleep Questionnaire - SSM Cardinal Glennon Children's Medical ...
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LabelPediatric <strong>Sleep</strong> and Research Center<strong>Sleep</strong>ing information:What time does child:Go to sleep: weekdays_______ weekends_______Awaken: weekdays_______ weekends_______Naps: length _______ # per day _______Does the Child:<strong>Sleep</strong> in their own room: _________ <strong>Sleep</strong> with parents: ________Share a room with siblings _________ Share a bed with siblings: ________<strong>Sleep</strong> in bed or crib: _________ <strong>Sleep</strong> with lights on: ________Listen to music to fall asleep: _________ Watch tv to fall asleep: ________<strong>Medical</strong> HistoryHeight:________ Weight:_________ (approximate if not known)Previous Hospitalizations and diagnostic testing (year and diagnosis):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tonsil and Adenoid Removal (when and where):________________________________Previous surgeries:_______________________________________________________________________________________________________________________________Current Medications: (Drug and Dosage)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family History:<strong>Sleep</strong> Disorders (what & whom):_____________________________________________________________________________________________________________Asthma or other lung disease (what & whom):___________________________________________________________________________________________________Other: __________________________________________________________________________________________________________________________________Allergies: (medication/latex)______________________________________________________________Please fill out questionnaire and bring with you to your appointment.
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