date of assessment: id#: sleep/w clinic/lab address: … · canada, by birth canada, by ... some...

Assessment Form | Extended Profile NeuroDevNet; Team Ipsiroglu, Copyright(c) Sleep/Wake-Behaviours Clinic & Research Lab

Dept. of Paediatrics BC Children’s Hospital, University of British Columbia

Patient Extended Profile

Primary language spoken at home:

English French Both English & French

Other Other (Specify):

Other language(s) spoken at home: English French Other Other (Specify):

Ethnicity: Aboriginal Latin American

Arab South Asian (e.g. East Indian, Pakistani)

Black Southeast Asian (e.g. Vietnamese, Malaysian)

Chinese West Asian

East Asian White

Filipino Other Other (specify):

Japanese Don’t know

Korean Prefer not to specify

Country of citizenship:

Canada, by birth Canada, by naturalization

Other country Other (specify):

Highest grade or level of education (at date of assessment):

Grade: 1 2 3 4 5 6 7 8 9 10 11 12 High school graduate

GED or equivalent

Some college, no degree Associate degree: occupational, technical, or vocational program

Associate degree: academic program Bachelor’s degree (e.g. NA,AB,BS,BBA)

Master’s degree (e.g. MA, MS, MBA) Professional school degree (e.g. MD, DDS, DVM, JD)

Doctoral degree (e.g. PhD, EdD) Unknown Never attended/Kindergarten only

Parent/Caregiver/Legal Guardian 1 - Extended Profile

Relationship to patient:

Biological mother Biological father Grandmother Grandfather

Step mother Step father Foster Mother Foster father

Adoptive mother Adoptive father Other Other (specify):

Marital Status: Never Married Separated Married

Divorced Widowed Domestic Partnership/Common-law relationship

Employment Status: Full time Part time Only temporarily laid off, sick leave, or maternity leave

Keeping house/ Homemaker

Looking for work, unemployed Disabled, permanently or temporary

Never employed Student Self-employed Retired Unknown

Other Other (specify):

Job Title (specify):



GED or equivalent




Doctoral degree (e.g. PhD, EdD) Unknown Doctoral degree (e.g. PhD, EdD)

Ethnicity:

Aboriginal Latin American



Chinese West Asian

East Asian White




Date of Assessment: ID#: Sleep/W

ake-

Behavio

ur Clinic

&

Researc

h Lab |

Date of

Assessm

ent

Clinic/Lab Address: _________________________________________________

Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Assessment Form | Extended Profile NeuroDevNet; Team Ipsiroglu, Copyright(c) Sleep/Wake-Behaviours Clinic & Research Lab


Parent/Caregiver/Legal Guardian 2 - Extended Profile

Relationship to patient:

Biological mother Biological father Grandmother Grandfather

Step mother Step father Foster Mother Foster father

Adoptive mother Adoptive father Other Other (specify):

Marital Status: Never Married Separated Married

Divorced Widowed Domestic Partnership/Common-law relationship

Employment Status: Full time Part time Only temporarily laid off, sick leave, or maternity leave

Keeping house/ Homemaker

Looking for work, unemployed Disabled, permanently or temporary

Never employed Student Self-employed Retired Unknown

Other Other (specify):

Job Title (specify):

Household income (from all sources), before taxes last year (in dollars): $

Number of people in participant’s household (including participant):

Residence Rural Town City under 500,000 people City over 500,000 people

Number of children (biological, step, adopted or foster children living in participant’s household

Sexes and ages of children in participants household (other than participant) (e.g. Male (12), …)

Number of adults in participant’s household:



GED or equivalent




Doctoral degree (e.g. PhD, EdD) Unknown Doctoral degree (e.g. PhD, EdD)

Ethnicity:

Aboriginal Latin American



Chinese West Asian

East Asian White




Additional Comments:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Date of Assessment: ID#: Sleep/W

ake-

Behavio

ur Clinic

&

Researc

h Lab |

Date of

Assessm

ent

Assessment Form | Paediatric Sleep Comfort Log & Diary Team Ipsiroglu, Copyright(c) Sleep/Wake-Behaviours Clinic & Research Lab Dept. of Paediatrics BC Children’s Hospital, University of British Columbia

Da

y

Instructions

Mid

nig

ht

1am

2am

3am

4am

5am

6am

7am

8am

9am

10am

11am

No

on

1p

m

2p

m

3p

m

4p

m

5p

m

6p

m

7p

m

8p

m

9p

m

10p

m

11p

m

_

Select when the child goes to bed:

(including naps) 12:0

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Select hours the child is actually asleep:

\\\ \

Select when the child wakes up:

(if unsure of exact time, estimate) 12:0

0

12:3

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1:0

0

1:3

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2:0

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11:3

0

Select when your child exercises (example: sports practice):

Notes:

Select when your child has disruptive episodes (example: tantrums):

Notes:

Select when your child takes medications (example: melatonin, ADHD):

Notes:

Select when your child eats/has a snack (example: apples, candy):

Notes:

Other: __________________________ (example: caffeine consumption)

Notes:

How was your child’s sleep quality last

night? (Select a face to the right)

Paediatric Sleep & Comfort Log & Diary

For consecutive nights, please indicate the sleep/wake patterns of your child:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Date:

ID #:

The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescents. Bruni et al. J Sleep Res, 5 (1996), pp 251-261

INSTRUCTIONS: This questionnaire will allow your doctor to have a better understanding of the sleep-wake rhythm of your child

and of any problems in his/her sleep behavior. Try to answer every question; in answering, consider each question as pertaining to the past 6 months of the child’s life. Select a single response per question.

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

5-7 hours

7-8 hours

8-9 hours

9-11 hours

How long after going to bed does your child usually fall asleep? less than 15' 15-30' 30-45' 45-60'

more

than 60'

Nev

er

Oc

ca

sio

na

lly

(1-2

tim

es p

er

mo

nth

or

less)

So

me

tim

es

(1-2

tim

es p

er

wee

k)

Oft

en

(3

-5 t

imes p

er

wee

k)

Alw

ays

(Daily

)

Please select the frequency the each of the following events occurs:

The child goes to bed reluctantly The child has difficulty getting to sleep at night The child feels anxious or afraid when falling asleep The child startles or jerks parts of the body while falling asleep The child shows repetitive actions such as rocking or head banging while falling asleep The child experiences vivid dream-like scenes while falling asleep The child sweats excessively while falling asleep The child wakes up more than twice per night After waking up in the night, the child has difficulty to fall asleep again The child has frequent twitching or jerking of legs while asleep or often changes position during the night or kicks the covers off the bed.

The child gasps for breath or is unable to breathe during sleep The child snores The child sweats excessively during the night You have observed the child sleepwalking You have observed the child talking in his/her sleep The child grinds teeth during sleep The child wakes from sleep screaming or confused so that you cannot seem to get through to him/her, but has no memory of these events the next morning

The child has nightmares which he/she doesn’t remember the next day The child is unusually difficult to wake up in the morning The child awakes in the morning feeling tired The child feels unable to move when waking up in the morning The child experiences daytime somnolence The child falls asleep suddenly in inappropriate situations

Please note that the below fields will automatically be calculated; compare values with ‘Appendix B: Scoring sheet’

DIMS: Disorders of initiating and maintaining sleep SBD: Sleep Breathing Disorders

DA: Disorders of arousal SWTD: Sleep-Wake Transition Disorders

DOES: Disorders of excessive somnolence SHY: Sleep Hyperhydrosis

Total score (sum 6 factors’ scores)

Sleep/Wake-Behaviour Assessment

©

The child’s mood at bedtime:

The child’s mood after a nighttime awakening:

The child’s mood when they wake up for the day:

Date of Assessment:

ID #:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Appendix A. SLEEP DISTURBANCES SCALE FOR CHILDREN – DECISION MAKING CODE Clinician: Use this reference sheet to calculate total score on the sleep disturbances scale for children (range: 26 to 130). Total score can be calculated by adding the factor scores (DIMS, SBD, DA, SWTD, DOES, SHY) as described at the bottom of this page. Note: record the total score in the space provided on the ‘Sleep Disturbances Scale for Children’ assessment form.

1. How many hours of sleep does your child get on most nights.

1 9-11 hours

2 8-9 hours

3 7-8 hours

4 5-7 hours

5 less than 5 hours

2. How long after going to bed does your child usually fall asleep

1 less than 15'

2 15-30'

3 30-45'

4 45-60'

5 more than 60'

5 Always (daily)

4 Often (3 or 5 times per week)

3 Sometimes (once or twice per week)

2 Occasionally (once or twice per month or less)

1 Never

3. The child goes to bed reluctantly 1 2 3 4 5

4. The child has difficulty getting to sleep at night 1 2 3 4 5

5. The child feels anxious or afraid when falling asleep 1 2 3 4 5

6. The child startles or jerks parts of the body while falling asleep 1 2 3 4 5

7. The child shows repetitive actions such as rocking or head banging while falling asleep 1 2 3 4 5

8. The child experiences vivid dream-like scenes while falling asleep 1 2 3 4 5

9. The child sweats excessively while falling asleep 1 2 3 4 5

10. The child wakes up more than twice per night 1 2 3 4 5

11. After waking up in the night, the child has difficulty to fall asleep again 1 2 3 4 5

12. The child has frequent twitching or jerking of legs while asleep or often changes position

during the night or kicks the covers off the bed.

1 2 3 4 5

13. The child has difficulty in breathing during the night 1 2 3 4 5

14. The child gasps for breath or is unable to breathe during sleep 1 2 3 4 5

15. The child snores 1 2 3 4 5

16. The child sweats excessively during the night 1 2 3 4 5

17. You have observed the child sleepwalking 1 2 3 4 5

18. You have observed the child talking in his/her sleep 1 2 3 4 5

19. The child grinds teeth during sleep 1 2 3 4 5

20. The child wakes from sleep screaming or confused so that you cannot seem to get through

to him/her, but has no memory of these events the next morning

1 2 3 4 5

21. The child has nightmares which he/she doesn’t remember the next day 1 2 3 4 5

22. The child is unusually difficult to wake up in the morning 1 2 3 4 5

23. The child awakes in the morning feeling tired 1 2 3 4 5

24. The child feels unable to move when waking up in the morning 1 2 3 4 5

25. The child experiences daytime somnolence 1 2 3 4 5

26. The child falls asleep suddenly in inappropriate situations 1 2 3 4 5

DIMS: Disorders of initiating and maintaining sleep (sum the score of the items 1,2,3,4,5,10,11)

SBD: Sleep Breathing Disorders (sum the score of the items 13,14,15)

DA: Disorders of arousal (sum the score of the items 17,20,21)

SWTD: Sleep-Wake Transition Disorders (sum the score of the items 6,7,8,12,18,19)

DOES: Disorders of excessive somnolence (sum the score of the items 22,23,24,25,26)

SHY: Sleep Hyperhydrosis (sum the score of the items 9,16)

Total score (sum 6 factors’ scores)

Appendix B. SDSC Scoring Sheet Clinician: use this form for reference to determine the child’s sleep profile. Compare the child’s T-score (see last column), total score and factor score. Higher scores indicate more disturbances, lower scores indicate less disturbances. Note: Values from this scoring sheet are for your reference during the assessment/follow-up assessment and are not to be recorded on the ‘Sleep Disturbances Scale for Children’ assessment form

T score DIMS SBD DA SWTD DOES SHY TOTAL T score

100+ 26+ 11+ 8+ 21+ 20+ 74+ 100+ 99 25 20 73 99 98 72 98 97 71 97 95 24 19 19 70 95 94 7 69 94 93 23 10 18 18 10 68 93 90 66 90 89 22 65 89 88 17 64 88 86 21 9 17 9 63 86 85 16 62 85 84 16 61 84 82 20 6 60 82 81 15 59 81 80 8 58 80 79 19 8 15 57 79 77 14 56 77 76 18 55 76 75 14 7 54 75 73 17 13 53 73 72 7 52 72

70 16 5 13 51 70 69 12 6 50 69 68 49 68 67 48 67 66 15 12 47 66 64 14 6 11 5 46 64 63 45 63 62 11 10 44 62 60 13 43 60 59 42 59 58 12 5 4 10 9 4 41 58 56 40 56 55 39 55 54 11 9 38 54 53 8 37 53 51 4 3 36 51

50 10 8 7 35 50

49 34 49 47 9 3 33 47 46 6 32 46 45 8 3 7 2 31 45 42 5 29 42 41 7 6 28 41 40 27 40 38 2 4 1 26 38

The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescents. Bruni et al. J Sleep Res, 5 (1996), pp 251-261

INSTRUCTIONS: Please write/type your comments in the space provided beside each question. Consider each question as pertaining to the past 6 months of the child’s life; if this is not applicable, please clarify which time frame the patient/parent is

referring to. Ask for best and worst case situations in order to understand the dimension of the underlying problem(s).

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

How long after going to bed does your child usually fall asleep?

The child goes to bed reluctantly: The child has difficulty getting to sleep at night: The child feels anxious or afraid when falling asleep: The child startles or jerks parts of the body while falling asleep: The child shows repetitive actions such as rocking or head banging while falling asleep:

The child experiences vivid dream-like scenes while falling asleep:

The child sweats excessively while falling asleep: The child wakes up more than twice per night: After waking up in the night, the child has difficulty to fall asleep again:

The child has frequent twitching or jerking of legs while asleep or often changes position during the night or kicks the covers off the bed: The child gasps for breath or is unable to breathe during sleep: The child snores: The child sweats excessively during the night: You have observed the child sleepwalking: You have observed the child talking in his/her sleep: The child grinds teeth during sleep: The child wakes from sleep screaming or confused so that you cannot seem to get through to him/her, but has no memory of these events the next morning:

The child has nightmares which he/she doesn’t remember the next day:

The child is unusually difficult to wake up in the morning: The child awakes in the morning feeling tired: The child feels unable to move when waking up in the morning: The child experiences daytime somnolence: The child falls asleep suddenly in inappropriate situations:

Please identify the main factors impacting well-being for the parent/guardian and child:

Parent/Guadian

Child

Sleep/Wake-Behaviour Assessment - Page 2 for comments

©

The child’s mood at bedtime:

The child’s mood after a nighttime awakening:

The child’s mood when they wake up for the day:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Date of Assessment:

ID #:

Perez-Chada, D., Perez-Lloret, S., Videla, A. J., Cardinali, D., Bergna, M. A., Fernández-Acquier, M., … Drake, C. (2007). Sleep Disordered Breathing And Daytime Sleepiness Are Associated With Poor Academic Performance In Teenagers. A Study Using The Pediatric Daytime Sleepiness Scale (PDSS). Sleep, 30(12), 1698–1703.

INSTRUCTONS: This questionnaire has been developed to measure daytime

sleepiness of middle-school children and examine the relationship between daytime sleepiness and school-related outcomes. Please answer the following questions as honestly as you can: Select a single response per question. N

ev

er

Se

ldo

m

So

me

tim

es

Oft

en

,

Fre

qu

en

tly

Ve

ry O

fte

n/

Alw

ay

s

0 1 2 3 4

1. How often so you fall asleep or get drowsy during class periods?

2. How often do you get sleepy or drowsy while doing your homework?

3. Are you usually alert most of the day? *Reverse score this item

4. How often are you ever tired and grumpy during the day?

5. How often do you have trouble getting out of bed in the morning?

6. How often do you fall back to sleep after being awakened in the morning?

7. How often do you need someone to awaken you in the morning?

8. How often do you think that you need more sleep?

Total score (sum of 8 scores)

Abnormal Values: 6th and 7th Grade > 26, 8th Grade >30

Additional Comments

Pediatric Daytime Sleepiness Scale (PDSS) - Iowa Sleep Disorders Center ©

Date of Assessment:

ID #:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Assessment Form | Medications Team Carr, Elbe (Pharmacy, BCCH), Ipsiroglu, Copyright(c) Sleep/Wake-Behaviours Clinic & Research Lab


Name of medication:

Dosages: Values(s) Unit Since when? Month Year

Frequency (per day) Helpfulness (mark with ‘X’):

When? (If taking multiple dosages, please specify

dosage in box)

Morning Afternoon Before bed

Noon Evening Other:

Route of administration: Oral Injection Sublingual

Inhalation Topical Rectal

Method:

With a meal With water On an empty stomach

With a snack With dairy products Other:

Prescribed for: Daytime (Identified problems):

Allergies/breathing/asthma Anxiety Thyroid

Adaptive behaviour/impulse Mood Gastrointestinal

Attention/Concentration Sensory problems/pain Seizures

Nighttime (Identified problems):

Allergies/breathing/asthma Falling asleep Maintaining sleep

Sensory problems Pain

Other:

Allergic Reaction:

If yes, please specify:

Yes No I don’t know

Skin rash Wheezing Swelling

Itchy skin Itchy, watery eyes Shortness of breath

Hives Fever Other:

Side effects:

If yes, please specify:


Headaches Increased movements Gastrointestinal

Mental clouding Fatigue Urinary

Sleep disturbances Abdominal pain Other:

When? Immediately Within a few hours Other:

Additional Comments:

Current Medications Please fill out a separate form for each medication

Date of Assessment:

ID #:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

Assessment Form | Nutrition Assessment Murthy (Dept. of Dietetics, CFRI); Team Ipsiroglu, Copyright(c) Sleep/Wake-Behaviours Clinic & Research Lab Dept. of Paediatrics BC Children’s Hospital, University of British Columbia

Height: Body Mass Index (BMI):

Weight: Recent weight change?

Gastrointestinal diagnoses:


Gastrointestinal reflux disease (GERD) Oral motor dysfunction

Gastrointestinal motility disorders Short gut syndrome

Failure to thrive Food allergies

Other (Specify):

Current Gastrointestinal Problems:


Frequent vomiting constipation

Nausea Mouth sores

Diarrhea Food allergies

Other (Specify):

Consistent bowel movement? Yes No I don’t know

Frequency per week

Feeding/Swallowing Problems:


Gastrostomy (G-tube) dependence Refusing to eat certain food groups

Oral motor & sensory problems Refusing to eat any solids or liquids

Choking/gagging/vomiting when eating Throwing tantrums at mealtimes

Type of feeding: Independent Partial assistance Dependent

Other (Specify):

Eating disorders: Yes No I don’t know

Anorexia nervosa Binge eating disorder

Bulimia nervosa Pica

Other (Specify):

Frequency of meals (per day) 1 2 3 4 5 Portion size: S M L XL

Snacks (per day) 0 1 2 3 4 5 Take-out/eating out (per day) 0 1 2 3 4 5

Servings of fruit/veg. (per day) 0 1 2 3 4 5 Serving of meat/poultry 0 1 2 3 4 5

Any food preferences or restrictions?


Vegetarian (no meat) Low fat

Pescatarian (plant based, with fish incl.) Low carb

Vegan (no animal products) Low sodium

Other (Specify):

Physical activity: Light Moderate Intense

Frequency (per week):

Additional Comments

Nutrition Assessment

Date of Assessment:

ID #:


Phone: _________________________________________________

Fax: ____________________________________________________

Email: __________________________________________________

date of assessment: id#: sleep/w clinic/lab address: … · canada, by birth canada, by ... some...

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