NEW PATIENT INFORMATION PEDIATRIC & TEEN

Transcription

1 Name: Date of Birth: Gender: PLEASE COMPLETE THE FOLLOWING (CHECK PRIMARY PHONE #) Street: City: State & Zip Code: Home: Work: Cell: FAMILY / EMERGENCY CONTACT (CHECK PRIMARY PHONE #) Name: Relationship to patient: Home: Work: Cell: SEND REPORTS TO THE FOLLOWING HEALTH CARE PROVIDERS: Name: Location: Phone: Name: Location: Phone: Name: Location: Phone: SLEEP HISTORY Based on the last 6 months, how many hours of sleep do you usually get at night? What is your typical bedtime? What is your typical waking time? Do these times differ on the weekend? NO YES If yes, how much? Where do you usually sleep? What sleep position do you prefer? Does anyone else sleep in your room? NO YES If yes, who? Do you watch TV before sleep? NO YES Do you read in bed before sleep? NO YES Do you use your bed for any other activities besides sleep? NO YES - In the 1 hour before bed do you: Nap NO YES Do homework NO YES Use a computer NO YES Use a cell phone NO YES Eat NO YES Exercise NO YES Listen to music NO YES Play any games NO YES Have you used any medications or supplements for sleep in the past? (please list) Have you ever been evaluated for a sleep problem? NO YES - _ Have you ever had sleep testing? NO YES When? Where? Page 1 of 6

2 SLEEP ONSET PLEASE CHECK ALL THAT APPLY Difficulty falling asleep Uncomfortable sleep environment My mind races with thoughts when I try to fall asleep I often worry whether or not I will be able to fall asleep I need someone else with me to fall asleep (who?) I sense a presence in my room or see lifelike visions (people in room, etc) as I fall asleep I feel an inability to move as if paralyzed while trying to go to sleep Urge to move my legs / arms Wiggle or kick to fall asleep Have growing pains Often cannot find a comfortable position I am scared to be alone in my room DURING SLEEP PLEASE CHECK ALL THAT APPLY I snore / been told I snore I gasp for breath during sleep I sweat in my sleep I get headaches at night Often have a dry mouth at night Told I stop breathing in sleep I sense a presence in my room or see lifelike visions (people in room, etc) if I wake up I feel an inability to move as if paralyzed if I wake during the night Urge to move legs / arms I kick a lot during sleep Mouth-breather in sleep I sleep walk / run I sleep talk / scream I have sleep terrors I act-out dreams I go to another room/bed during the night to sleep I wake to use the bathroom more than once/night I wet the bed (how often) Difficulty remaining asleep I grind my teeth in my sleep IN THE MORNING & DAY PLEASE CHECK ALL THAT APPLY I am not rested when I awaken I feel sleepy during the day Others say I am sleepy in day Awaken too early Awaken with a dry mouth Morning headaches Have difficulty concentrating Have trouble remembering I am often irritable If you nap, My naps are refreshing I dream in naps I nap out of my bed I feel an inability to move as if paralyzed when I wake up I notice a sudden weakness or feel my body go limp if I laugh hard, get surprised, or get very upset (circle) Often feel depressed Often feel anxious Feel hyperactive Have you used any medications to stay awake or to focus in the past? (please list) Page 2 of 6

3 PEDIATRIC DAYTIME SLEEPINESS SCALE If you are in school, please answer the following questions as honestly as you can by circling one answer only: Question: How often do you fall asleep or get drowsy during class periods? How often do you get sleepy or drowsy while doing homework? Always Frequently Sometimes t often Never Always Frequently Sometimes t often Never Are you usually alert most of the day? Never t Often Sometimes Frequently Always How often are you ever tired and grumpy during the day? How often do you have trouble getting out of bed in the morning? How often do you fall back to sleep after being awakened in the morning? How often do you need someone to awaken you in the morning? Always Frequently Sometimes t often Never Always Frequently Sometimes t often Never Very often Often Sometimes t often Never Always Frequently Sometimes t often Never How often do you think you need more sleep? Very often Often Sometimes t often Never Total score MEDICAL HISTORY (CHECK ALL THAT APPLY) ADHD / ADD Diabetes Anemia or Iron Deficiency Headaches Anxiety / Depression High Blood Pressure Asthma / Lung Disease High Cholesterol or Lipids Autism spectrum disorder Mental retardation Brain Injury or Surgery Reflux or Ulcer Cancer Seizures Developmental delay Thyroid Disease Other medical conditions & Month/Year of diagnoses or symptoms -- Please list: Page 3 of 6

4 SURGICAL HISTORY (INCLUDE MONTH/YEAR) MEDICATIONS OR SUPPLEMENTS (INCLUDE DOSE & TIMES PER DAY) ALLERGIES TO MEDICATIONS FAMILY HISTORY List immediate family members (include SIBLINGS & BIOLOGICAL RELATIVES) and any Medical Conditions or Chronic Diseases below: Relationship & Age: Living? Illness/Disease & Decade of Onset (20 s, 30 s, etc ): Mother Father Page 4 of 6

5 BIRTH / CHILDHOOD HISTORY Was delivery Full Term? If, how premature weeks Was delivery C-section? If yes, why? Any complications at Birth? If, what? Any home monitoring after Birth? If, what kind? Any developmental delay? If yes, what kind? Any special needs or therapy? If yes, what kind? SOCIAL HISTORY Ethnicity: Hispanic or Latino American Indian or Alaska Black or African American Southeast Asian Native Hawaiian or Other Pacific Islander White or Caucasian Asian Other Which # child in birth order are you in your family? Grade Level: Special Education Requirements? Who lives at home with you? List after school activities performed (include # days / week and hrs / day): Do you use tobacco? cigs / cans /day for years Do you drink caffeinated beverages? cups / cans /day (Include colas, coffee, iced & hot teas) If YES, what time is your last caffeinated drink? Have you ever used drugs or alcohol? If yes, which one(s) (TIFJU00020) Page 5 of 6

6 REVIEW OF SYSTEMS PLEASE CHECK YES OR NO DO YOU CURRENTLY OR HAVE YOU RECENTLY (LAST 6 MONTHS) EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS? VISION Seeing double... Blindness... Cataracts... Glasses... HEARING Deafness... Hearing aide... Ringing in the ears... HEAD & NECK Nasal congestion / obstruction... Difficulty swallowing... Ear pain / infections... Throat pain / infections... se bleeds... Eye pain / infections... Loss of taste... Loss of voice... CARDIOVASCULAR Murmur... Irregular heart rate... Chest pain / tightness at rest... Heart racing... Swollen ankles or legs... Palpitations... PULMONARY Shortness of breath at rest... Shortness of breath w/exercise... Coughing... Wheezing... Tightness in chest... GASTROINTESTINAL Nausea... Vomiting... Abdominal pain... Diarrhea... Constipation... Bright red or black stools... Heartburn... GENITOURINARY Bed wetting... Puberty reached... Menarche reached... (TIFJU00020) MUSCULOSKELETAL Joint pain / swelling... Muscle pain/ swelling... Varicose veins... Back /neck pain... TMJ... NEUROLOGICAL Migraines / headaches... Seizures... Dizziness... Weakness... Numbness... Speech / language problems... Balance problems... Tics / Tremors... PSYCHIATRIC Inattention... Hyperactivity... Anxiety... Depression... Suicidal thoughts... Suicide attempts... Obsessive / Compulsive... Mania / Bipolar... ENDOCRINE Hair changes... Thirst changes... Temperature changes... Weight gain... Weight loss... Increased appetite... Decreased appetite... ALLERGY/IMMUNOLOGIC Frequent infections... Swollen lymph nodes... HEMATOLOGIC Easy bruising... Easy bleeding... Blood Clots... SKIN Itchiness... Rashes... Page 6 of 6