Personal
Child Sleep History
Date:
Child’s Name:
Address
City, Zip
PLEASE MAIL Date of Birth: Height: Weight:
OR FAX AS
SOON AS Referring Referring
Physician Phys. Office #
POSSIBLE TO
AN ADDRESS
BELOW Parent Info
Date of
Parent’s Name: Birth:
Address
City, Zip
SANTA CLARITA
Tel:661-799-1428 Home # Work #
Fax:661-799-0968
25050 Peachland Social Security # Cell #
Ave., Suite 125,
Santa Clarita, CA
91321 Chief Complaint Please Explain:
Trouble falling asleep
Sleepy all day
PASADENA Unwanted behaviors while sleeping
Tel: 626-795-9090 Other
Fax:626-795-9605
1W. California,
Suite 514 Medication
Pasadena, CA
91105 Name of Drug Dosage Doses per day Reason
Child Sleep History
Allergies Please give details, describe your reaction
Surgeries / Operations and Other Medical Problems Please give details, date
Excessive daytime sleepiness
Never Rarely Sometimes Frequently
Is your child difficult to wake in the morning, act sleepy,
or seem overtired a lot?
How does your child act when she is overtired?
Does your child fall asleep during the day? When and where?
Does anyone else in the family have a problem with excessive
sleepiness?
Awakenings: night waking, early morning waking
Never Rarely Sometimes Frequently
Does your child have trouble with waking up at night?
What do you think awakens him?
How does your child behave when she awakens at
night?
Does your child move to someone else’s bed during
the night?
Regularity and duration of sleep
Schooldays Weekends
What time does your child go to bed and get up on go to bed get up go to bed get up
schooldays? weekends?
Do you think your child is getting enough sleep?
How much sleep do you think your child needs?
Snoring
Never Rarely Sometimes frequently
Does your child have loud or nightly snoring?
Does your child ever stop breathing, choke or gasp at night?
Is your child a restless sleeper? Sweat a lot at night?
Do other people in your family snore loudly?
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Child Sleep History
Insurance Information
PRIMARY INSURANCE:
Company Name:
Mailing Address:
Zip Code:
Relationship
City/State:
to Patient:
Name of Subscriber: Subscriber’s DOB
Policy Number: Group #
ID Number: Effective Date:
SECONDARY INSURANCE COMPANY:
Company Name:
Mailing Address:
Zip Code:
Relationship
City/State:
to Patient:
Name of Subscriber: Subscriber’s DOB
Policy Number: Group #:
ID Number: Effective Date:
Payment Policy: Payment is due at the time services are rendered unless other
arrangements have been made. Insurance is considered a method of reimbursing the
patient for fees paid to the doctor, and is not a substitute for payment. It is your
responsibility to pay any deductible, co-insurance, or any balance not paid by your
insurance. Our Policy allows a maximum of 90 days for insurance companies to pay
claims. If this does not occur, you will be expected to pay the balance to NYX.
Patient Authorization: I hereby authorize the release of any medical information
necessary to process my insurance claim. I hereby authorize payment of medical benefits
to the named provider for services rendered. I also authorize Palmetto GBA to release
information regarding Medicare claims submitted by the named provider.
This office requires a 48-hour advance notice of cancellation when a sleep study has
been scheduled. If not given, NYX reserves the right to charge a $175 non-refundable
fee to the person responsible for the patient listed above and/or decide if the patient will
be re-scheduled for a later date.
SIGNED: DATE:
(Patient or Guardian if Minor)
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