Priority Pediatrics PC

Available Forms

1. NEW Patient Online Intake History Form for Dr. T 2. ESTABLISHED Patient Online Interim History Form for Dr. T 3. Lead Exposure Risk Questionnaire for parent to complete for Dr. T 4. Request to Transfer Medical Records to Priority Pediatrics 5. Pediatric Symptom Checklist for PARENTS of 11-18 Year Olds to Complete for Dr. T 6. Pediatric Symptom Checklist for YOUTH ages 11-18 Years to Complete for Dr. T 7. Adolescent Mood Questionnaire for the Teen to complete for Dr. T 8 Side Effect Patient Check List 9. Tuberculosis (TB) Exposure Risk Questionnaire to complete for Dr. T 10. Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

10. Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed in more than one seating if needed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

If you feel your child is NOT having restful quiet sleep, please complete this questionnaire and send to Dr. T. Thank you.

Name of Child *

Name of Person(s) completing quesitonnaire *

Date Questionnaire Completed *

Sleep-Related Breathing Problem Questionnaire

While sleeping, does your child...

...snore more than 1/2 the time? *

Yes

DN (Don't Know)

...always snore? *

Yes

...snore loudly? *

Yes

...have "heavy" or loud breathing? *

Yes

...have trouble breathing, or struggle to breathe? *

Yes

Have you ever...

...seen your child stop breathing during the night? *

Yes

Maybe

Long pauses in breathing > 10 seconds.

Does your child...

...tend to breathe through the mouth during the day? *

Yes

Maybe

Mouth is generally open through the day for breathing.

...have a dry mouth on waking up in the morning? *

Yes

...occasionally wet the bed? *

Yes

How often?

Does your child...

...drench his/her PJ's overnight with perspiration/sweat as if had been in a swimming pool. *

Yes

Maybe

...wake up feeling UNrefreshed in the morning? *

Yes

...have a problem with sleepiness during the day? *

Yes

...have a teacher or other supervising adult who comments that your child appears sleepy during the day? *

Yes

...make it difficult for you to wake him/her up in the morning? *

Yes

...wake up with headaches in the morning? *

Yes

...have problems growing at a normal rate or speed at any time since birth? *

Yes

...have problems with being overweight? *

Yes

This child often...

...does NOT seem to listen when spoken to directly. *

Yes

...has difficulty organizing tasks and activities. *

...is easily distracted by extraneous stimuli. *

Yes

...fidgets with hands or feet or squirms in seat. *

Yes

...is "on the go" or often acts as if "driven by a motor." *

Yes

...interrupts or intrudes on others (e.g. butts into conversations or games). *

Yes

Please tell me more about any of the above answers that you wish.

* Required field