Pediatric Comprehensive Health Questionnaire

Demographic Information
Contact Information
Provider Information

Patient/Parent Signature:

What is your chief concern and reason for this visit:

Does your child currently experience any of the following symptoms?
Indicate all that apply and number your top chief complaints 1-4
Sleep Conditions
Pain Conditions
Other Conditions
Surgical History

Patient/Parent Signature:

Allergic Reactions
Please check any and all medications or substance that have caused an allergic reaction
Current Medications
Please list all medications and supplements (over‑the‑counter and prescription) you are taking and the reason you take them.
Medication
Dosage
Reason for Taking
Previous Treatment, Medications and Other Therapies Attempted For The Condition We Are Evaluating
Treatment/Med/Therapy
Doctor/Provider
Approx. Date of Tx Helpful(y/n)
History of Symptoms
Has your child had any of the following:

Patient/Parent Signature:

Medical History

I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, third party billing companies, or for legal documentation to process claims.I understand that I am responsible for all charges incurred for my treatment regardless of insurance coverage.

Patient/Parent Signature:

Bears Sleep Screening

The “BEARS” instrument is divided into five major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children in the 2-to 18-year old range. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview.

B = bed time problems
E = excessive daytime sleepiness
A = awakenings during the night
R = regularity and duration of sleep
S = snoring

A parent answers questions in black, the subject child answers questions written in blue:

Symptom

Age Toddler/Preschool (2-5 years)

Age School Age (6-12 years)


Age Adolescent (13-18 years)

Symptom

Age Toddler/Preschool (2-5 years)

Age School Age (6-12 years)


Age Adolescent (13-18 years)



Symptom

Age Toddler/Preschool (2-5 years)

Age School Age (6-12 years)




Age Adolescent (13-18 years)


Symptom

Age Toddler/Preschool (2-5 years)


Age School Age (6-12 years)

Age Adolescent (13-18 years)

Symptom

Age Toddler/Preschool (2-5 years)

Age School Age (6-12 years)

Age Adolescent (13-18 years)

(P) Parent-directed question

(C) Child-directed question

Source: “A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems” by Jodi A. Mindell and Judith A. Owens;Lippincott Williams & Wilkins

Patient/Parent Signature:

PEDIATRIC SLEEP QUESTIONNAIRE (PSQ)
1. While sleeping does your child....
2. Does your child.....
5. This child often.....

Patient/Parent Signature: