Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
Authorization and Consent for Sleep Testing
·
I authorize the release of any medical information necessary to the durable medical equipment company for
therapy, if applicable.
·
I authorize the use of audio and video monitoring during my sleep study.
·
I have received and understand the instructions for the sleep study.
·
In addition to the ordering provider, I consent to discussion of sleep study results to spouse and next of kin. ( If
you do not wish us to discuss results with spouse or next of kin, please check the following box and write the
names of the persons you do not wish us to discuss your results with.
__________________________________________________________
I release Dr. Saad S. Ahmad / TriCity Lung Associates, PLC from any responsibility that may arise from the release of these records. I authorize Dr. Saad S. Ahmad /
TriCity Lung Associates, PLC to release information contained in my medical records, including as applicable: Alcohol and drug abuse and mental health treatment
information protected under the regulation title 42 of the code of Federal Regulations Part 2, information about communicable diseases and infections, as defined by
Department of Public Health rules ( Michigan Public Health Code) Which includes venereal disease, tuberculosis, Human immunodeficiency virus-HIV, acquired
immunodeficiency syndrome-AIDS and AIDS related complex-ARCThis consent will expire on the year after the date signed.
Patient Name (PRINT)________________________________________________________ Date of birth: ______________________
Signature of parent or guardian: _______________________________________________________Date: ____________________
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
Pediatric Sleep Questionnaire
Please state, in your own words, the reason why you (or your doctor) contacted our clinic:
__________________________________________________________________________________________________
_____________________
At what age did this problem begin? _____________
Has it changed? NO / YES: How? ________________________________________
_________________________________________________________________________________________
MEDICATION ALLERGIES:
CHILD’S CURRENT HISTORY - MY CHILD HAS THE FOLLOWING:
___ Asthma
_______ Sounds congested
_______ Has frequent ear infections
_______ Frequent strep throat
_______ Has frequent colds
_______ Acid reflux
_______ Chronic bronchitis
_______ Heart problems
_______ Neurological problems
_______ Bipolar/Depression
_______ ADHD/ ADD/ ODD
_______ Down’s Syndrome
_______ Delayed growth
_______ Developmental delay
_______ Prader Willie
_______ Learning disability
_______ Autism
_______ Allergies ___________
_______ Thyroid problem
_______ Epilepsy/ Seizures
CHILD‘S FAMILY HISTORY Does anyone in your family, have a sleep problem? Describe whom and type of problem:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
MEDICATIONS:
Please list the name and doses of all medications taken now, or that have been taken within the last 30 days:
MEDICATION NAME
DOSAGE (MG)
REASON
Past Medications: Name of all medications the patient has taken within the last year:
MEDICATION NAME
DOSAGE (MG)
REASON
Ears, Nose and Throat Surgeries)
Adenoids and tonsils removed? Yes or No
Date:___________ Surgeon: ___________
Others: ____________________ Yes or No
Date:___________ Surgeon: ___________
Child’s birth information:
Was this a normal delivery?
NO / YES: Explain:
Born earlier than due date?
NO / YES: How much earlier?
Was oxygen needed at birth? NO / YES: Tube feedings? NO / YES ;
Extended stay after birth?
NO / YES: How long?
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
CHILD’S SOCIAL HISTORY
Caffeinated beverages (Cola, Mountain Dew, iced tea): __________/day (amount)
Child’s grades: ____________________________
Is your child enrolled in a special education class?
Y/ N
Members of the family living with the child in the same House:__________________________________
Indoor Pets: _____________________________________________________________________________
Does anybody smoke in the house? __________________________________________________________
SLEEP SCHEDULE
WEEKDAYS
WEEKENDS/VACATIONS
1. Child’s usual bedtime
_________ AM/PM
_________ AM/PM
2. Child’s usual awake time
_________ AM/PM
_________ AM/PM
3. Child’s sleep duration per night?
_________ HOURS
_________ HOURS
4. Time to fall asleep?
__________MIN
_________ MIN
5. Number of awakenings each night?
__________TIMES
6. Duration of awakenings?
__________HOURS/MIN
NAPS
Number of days each week your child takes a nap. ____________
Usual nap times. Nap1: ___________________Nap2:___________________Nap3__________
ABOUT FALLING ASLEEP
1. Does the child have a regular bedtime routine?
YES/ NO
2. Does the child have his/her own bedroom?
YES / NO ;
His/Her own bed?
YES / NO
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
3. Is a parent present when your child falls asleep? YES /NO
4. Child usually falls asleep in:
____Own room in own bed (alone) ___Parents’ room in own bed ___Parents’ room in
parents’ bed ____Sibling’s room in own bed
___Sibling’s room in sibling’s bed
5. Child sleeps most of the night in: __Own room in own bed (alone) ___Parents’ room in own bed ___Parents’ room
in parents’ bed
__Sibling’s room in own bed
___Sibling’s room in sibling’s bed
6. Child usually wakes up in the morning: __Own room in own bed (alone) __Parents’ room in own bed
__Parents’ room in parents’ bed
7. Child resists going to bed?
8. Child has difficulty falling asleep?
__Sibling’s room in own bed __Sibling’s room in sibling’s bed
YES / NO
YES / NO
9. Uncomfortable feeling in child’s legs/arms such as creepy/crawly feeling?
YES / NO
ABOUT SLEEP (check all that are true)
1. Child is a poor sleeper?
YES / NO
2. Child has a restless sleep?
YES / NO
3. During sleep, my child: (check all that are true)
_______Snores
_______Stops breathing
_______Has night terrors
_______Snores loudly
_______Looks pale or blue
_______Sleepwalking
_______Snores continuously
_______Sweats when sleeping
_______Sleep talking
_______Gasps for air
______ Wets bed
_______ Nightmares
_______Makes choking sounds
Rocks his/her body
_______ Grinds his/hers teeth
_______Has a heavy breathing
_______Kicks legs in sleep
______ Get out of bed at night
_______ Struggles breathing
Bang his/her head
_______Uncomfortable feeling in child’s legs; creepy or crawly feeling.
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
ABOUT AWAKENING (check all that are true)
_______Is difficult to awaken in the morning _______Is difficult to get out of bed in the morning
Headaches in the morning
_______ Bed sheets found disorganized
_______Seems groggy in the morning
_______Has no appetite in the morning
_______Complains of feeling tired
_______Has trouble getting dressed
DURING THE DAY (check all that are true)
______Is “on the go” and acts as if “driven by a motor”
______Breathe through the mouth
______Is easily distracted by extraneous stimuli
______Swallowing problems
______Is sleepy during the day
______Reports unable to move when falling asleep or upon awakening
______Sees frightening visual images before falling asleep or upon awakening
______Becomes weak/looses muscle tone, when excited, angry or laughing (jaw or head dropping, knee
buckling, falling on the floor, difficulty talking) for1-2 minutes?
For children over 5 years of age: My child: (check all that are true)
_______Seems hyperactive
_______Does more poorly at school than expected
_______ Is impulsive
_______Learning problems
_______Has behavioral/acting problems
_______Seems very sensitive
_______Becomes easily upset
_______Seems excessively anxious
_______Falls asleep in school
_______Has difficulty making close friends
_______Falls asleep in odd situations or places _______Has problems with attention
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
Additional Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
EPWORTH SLEEPINESS SCALE
In contrast to just feeling tired, how likely is your child to doze off or fall asleep in the following
situations? Even if you have not done some of these things recently, try to work out how they would
have affected you. Use the following scale to choose the most appropriate number for each situation.
0 = WOULD NEVER DOZE
1 = SLIGHT CHANCE OF DOZING
2 = MODERATE CHANCE OF DOZING
3 = HIGH CHANCE OF DOZING
SITUATION
CHANCE OF DOZING
Sitting and Reading …circle one
Watching TV …circle one
Sitting inactive in a public place (i.e., in a theatre) …circle one
As a car passenger for an hour without a break…circle one
Lying down to rest in the afternoon …circle one
Sitting and talking to someone…circle one
Sitting quietly after lunch (without alcohol) …circle one
In a car, while stopping for a few minutes in traffic…circle one
0
0
0
0
0
0
0
0
TOTAL SCORE = ___________
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Huron Medical Sleep Center
Saad S. Ahmad, MD
1100 S Van Dyke ∙ Bad Axe, Michigan 48413
(989) 269-1565 ∙ FAX (989)269-1555 ∙ www.huronmedicalcenter.org
Sleep Log
Complete this sleep log as instructed using the directions provided below. Complete the log in the morning and in the evening. Write additional
comments on the back.
a BLACKEN in the times when you are sleeping.
b DOWN ARROW indicating the time you are in bed to sleep.
c UP ARROW indicating when you got out of bed.
Example:
6am
8am
8am
10am
10am
Noon
2pm
4pm
6pm
8pm
10pm
MN
2am
4am
In the sample sleep log, this person got out of bed until 9am. Then he/she laid in bed for an afternoon nap at noon and fell asleep within minutes. When he/she woke up at 2pm, he/she
immediately got out of bed. In the evening, this person went to bed at 9pm, but did not fall asleep until 10pm. During the night, this person was awake from 4am to 5am, but did not get out of bed.
Again, he/she slept until 8am and got out of bed at 9am.
**Please fill out this sleep study- recording your sleep routine for the week prior to your sleep study**
DAY
6am
8am
8am
10am
10am
Noon
2pm
4pm
6pm
8pm
10pm
MN
1
2
3
4
5
6
7
***Please Complete This Questionnaire and Bring It with You on the Night of Your Study. ***
If You Have Any Questions, Please Feel Free To Call Us
2am
4am