Dr. Shayan Makvandi Consultation Form

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Patient Demographics & Intake Context

First Name:

Last Name:

Date of Birth:

Health Card Number (HSC#):

Gender:

Male Female

Height (cm):

Weight (kg):

Referring Physician:

Questionnaire Filled Out By:

Mom Dad Other

What are your major concerns about your child's sleep?

Has your child had a sleep study before?

Yes No

If yes, When:

Where:

Past Medical History Profile

Medical Conditions Checklist:

Please list all your child's medical problems if not listed above:

Past Psychiatric/Psychological History Matrix:

Please list any additional behavioural problems suspected or diagnosed by a physician/psychologist:

Surgical Parameters History Context:

Tonsils Removed:

Yes No

Adenoids Removed:

Yes No

Ear Tubes Placed:

Yes No

History of Head Trauma:

Yes No

Other Procedures Info:

Current Medications Inventory Stack:

Medication Identity Name	Dosage Parameters	Frequency Settings	Action

Does your child drink caffeinated beverages (Pepsi, iced tea)?

Yes No

Does your child have any medication allergies?

Yes No

Current School Performance Parameters

Your child is in what grade?

Is your child enrolled in special education class?

Yes No

Child's grades this year:

Any behavioral concerns at school?

Yes No

If yes, please specify details:

Sleep History

1. Does your child nap during the day?

Yes No

If yes: how often / how long?

2. What time does your child normally go to sleep?

3. How long does it usually take for your child to fall asleep?

4. What time does your child wake up in the morning?

5. How many hours of sleep does your child get most nights?

6. Is your child’s sleep schedule different on the weekends?

Yes No

7. Does your child sleep in his/her own bed?

Yes No

Behavioral & Physiological Indicator Grid

Observed Clinical Indicator Descriptions	Never	Occasional	Always
Appears to be struggling to breathe during sleep
Snoring
Mouth breathe
Gasp for air
Stop breathing during sleep
Appear congested
Have restless sleep
Wake up more than twice/night
Has excessive night sweats (soaks sheets)
Sleep walks
Sleep talks
Grinds teeth
Nightmares
Wets the bed
Have difficulties waking up
Wake up feeling tired
Have headaches in the morning
Suddenly falls asleep at inappropriate times (e.g. school, watching TV)
Napping after school

If bed wetting occurs, has your child ever been dry at night previously?

Yes No

Family Medical & Sleep History

Is there a family history of sleep or medical problems?

Yes No

If yes, please specify details:

Modified Epworth Sleepiness Scale (ESS)

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation:

0 Would NEVER doze

1 SLIGHT chance

2 MODERATE chance

3 HIGH chance

Situation	0	1	2	3
1. Sitting and reading
2. Watching TV
3. Sitting inactive in a public place (e.g. movie theater or a meeting)
4. As a passenger in a car/bus for an hour without a break
5. Lying down to rest in the afternoon when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after lunch
8. In a car/bus, while stopped for a few minutes in traffic

Epworth Score Total: 0 / 24

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Epworth Score Total: 0 / 24

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