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Protocol - Sleep Apnea - Child

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Protocol Name from Source:

The Pediatric Sleep Questionnaire (PSQ)

Availability:

Publicly available

Description:

See the protocol section for how to access this protocol

Protocol:

The Pediatric Sleep Questionnaire (PSQ) can be licensed and obtained at [link[secure.nouvant.com/umich/technology/3766/license/7|https://secure.nouvant.com/umich/technology/3766/license/7]]

© 2007 The Regents of the University of Michigan

Personnel and Training Required

None

Equipment Needs

None

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Toddler, Child, Adolescent

Specific Instructions:

The Pediatric Sleep Questionnaire (PSQ) is a proprietary questionnaire. See protocol section for how to obtain the questionnaire.

Research Domain Information

Release Date:

November 28, 2017

Definition

This measure identifies people with sleep apnea.

Purpose

Sleep apnea is a serious, potentially life-threatening condition that is far more common than is generally understood. Sleep apnea occurs in all age groups and both genders.

Selection Rationale

This protocol was chosen because of its validation in several age groups of children, because of its relative ease of administration, and because it can be used in large cohorts.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)Person Sleep Apnea Text2970224CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Resp sleep apnea child proto62637-4LOINC

Process and Review

[link[phenx.org/node/118|Expert Review Panel #6]] (ERP 6) reviewed the measures in the Respiratory domain.

Guidance from the ERP 6 includes:

• Link to proprietary protocol provided

Back-compatible: no changes to Data Dictionary

Previous version in Toolkit archive ([link[www.phenxtoolkit.org/index.php?pageLink=browse.archive.protocols&id=90000|link]])

Source

University of Michigan, Pediatric Sleep Questionnaire, Version 070424

General References

Chervin, R. D., Hedger, K., Dillon, J. E., & Pituch, K. J. (2000). Pediatric Sleep Questionnaire (PSQ): Validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine, 1, 21-32.

Chervin, R. D., Weatherly, R. A., Garetz, S. L., Ruzicka, D. L., Giordani, B. J., Hodges, E. K., Dillon, J. E., & Guire, K. E. (2007). Pediatric Sleep Questionnaire: Prediction of sleep apnea and outcomes. Archives of Otolaryngology-Head & Neck Surgery, 133, 216-222.

Protocol ID:

91502

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX091502_Interview_DatePX091502010000Today's Date?4N/A
PX091502_Interview_LocationPX091502020000Where are you completing this questionnaire?4N/A
PX091502_Child_Birth_DatePX091502030000Date of Child's Birth?4N/A
PX091502_Child_GenderPX091502040000Sex?4N/A
PX091502_Child_Height_FeetPX091502050100Current Height (feet/inches)?4N/A
PX091502_Child_Height_InchesPX091502050200Current Height (feet/inches)?4N/A
PX091502_Child_Weight_PoundPX091502060000Current Weight (pound)?4N/A
PX091502_Child_Grade_In_SchoolPX091502070000Grade in school (if applicable)?4N/A
PX091502_Child_Racial_EthnicPX091502080000Racial/Ethnic Background of your Child?4N/A
PX091502_Child_Snore_EverPX091502090100WHILE SLEEPING, DOES YOUR CHILD ever snore?4N/A
PX091502_Child_Snore_More_Half_TimePX091502090200WHILE SLEEPING, DOES YOUR CHILD snore more than half the time?4N/A
PX091502_Child_Always_SnorePX091502090300WHILE SLEEPING, DOES YOUR CHILD always snore?4N/A
PX091502_Child_Snore_LoudlyPX091502090400WHILE SLEEPING, DOES YOUR CHILD snore loudly?4N/A
PX091502_Child_Heavy_Loud_BreathingPX091502090500WHILE SLEEPING, DOES YOUR CHILD have "heavy" or loud breathing?4N/A
PX091502_Child_Trouble_Struggle_BreathingPX091502090600WHILE SLEEPING, DOES YOUR CHILD have trouble breathing, or struggle to breathe?4N/A
PX091502_Child_Stop_Breathing_Night_EverPX091502100101HAVE YOU EVER seen your child stop breathing during the night?4N/A
PX091502_Child_Stop_Breathing_Night_DescriptionPX091502100102HAVE YOU EVER been concerned about your child's breathing during sleep?4N/A
PX091502_Shake_Wake_Sleeping_Child_BreathePX091502100300HAVE YOU EVER had to shake your sleeping child to get him or her to breathe, or wake up and breathe?4N/A
PX091502_Child_Wake_Snoring_Sound_EverPX091502100400HAVE YOU EVER seen your child wake up with a snorting sound?4N/A
PX091502_Child_Restless_SleepPX091502110100DOES YOUR CHILD have restless sleep?4N/A
PX091502_Child_Restless_Legs_In_BedPX091502110200DOES YOUR CHILD describe restlessness of the legs when in bed?4N/A
PX091502_Child_Growing_Unexplained_Leg_PainsPX091502110300DOES YOUR CHILD have "growing pains" (unexplained leg pains)?4N/A
PX091502_Child_Growing_Pains_Worst_BedPX091502110400DOES YOUR CHILD have "growing pains" that are worst in bed?4N/A
PX091502_Child_Legs_Brief_KicksPX091502120100WHILE YOUR CHILD SLEEPS, HAVE YOU SEEN brief kicks of one leg or both legs?4N/A
PX091502_Child_Legs_Repeated_Kicks_RegularPX091502120200WHILE YOUR CHILD SLEEPS, HAVE YOU SEEN repeated kicks or jerks of the legs at regular intervals (i.e., about every 20 to 40 seconds)?4N/A
PX091502_Child_Night_Sweaty_Wet_PerspirationPX091502130100AT NIGHT, DOES YOUR CHILD USUALLY become sweaty, or do the pajamas usually become wet with perspiration?4N/A
PX091502_Child_Night_Get_Out_BedPX091502130200AT NIGHT, DOES YOUR CHILD USUALLY get out of bed (for any reason)?4N/A
PX091502_Child_Night_UrinatePX091502130301AT NIGHT, DOES YOUR CHILD USUALLY get out of bed to urinate?4N/A
PX091502_Child_Night_Urinate_TimesPX091502130302If YOUR CHILD USUALLY get out of bed to urinate, how many times each night, on average?4N/A
PX091502_Child_Sleep_Mouth_OpenPX091502140000Does your child usually sleep with the mouth open?4N/A
PX091502_Child_Congested_Stuffed_Nose_NightPX091502150000Is your child's nose usually congested or "stuffed" at night?4N/A
PX091502_Child_Allergies_Affect_Breathe_NosePX091502160000Do any allergies affect your child's ability to breathe through the nose?4N/A
PX091502_Child_Breathe_Through_Mouth_DayPX091502170100DOES YOUR CHILD tend to breathe through the mouth during the day?4N/A
PX091502_Child_Dry_Mouth_Waking_MorningPX091502170200DOES YOUR CHILD have a dry mouth on waking up in the morning?4N/A
PX091502_Child_Upset_Stomach_NightPX091502170300DOES YOUR CHILD complain of an upset stomach at night?4N/A
PX091502_Child_Burning_Throat_NightPX091502170400DOES YOUR CHILD get a burning feeling in the throat at night?4N/A
PX091502_Child_Grind_Teeth_NightPX091502170500DOES YOUR CHILD grind his or her teeth at night?4N/A
PX091502_Child_Wet_BedPX091502170600DOES YOUR CHILD occasionally wet the bed?4N/A
PX091502_Child_Sleep_WalkingPX091502180000Has your child ever walked during sleep ("sleep walking")?4N/A
PX091502_Child_Sleep_TalkingPX091502190000Have you ever heard your child talk during sleep ("sleep talking")?4N/A
PX091502_Child_NightmarePX091502200000Does your child have nightmares once a week or more on average?4N/A
PX091502_Child_Wake_Up_Screaming_NightPX091502210000Has your child ever woken up screaming during the night?4N/A
PX091502_Child_Neither_Awake_Asleep_EverPX091502220100Has your child ever been moving or behaving, at night, in a way that made you think your child was neither completely awake nor asleep? 4N/A
PX091502_Child_Neither_Awake_Asleep_EverDescribePX091502220101Has your child ever been moving or behaving, at night, in a way that made you think your child was neither completely awake nor asleep? If so, please describe what has happened: 4N/A
PX091502_Child_Difficulty_Falling_Asleep_NightPX091502230000Does your child have difficulty falling asleep at night?4N/A
PX091502_Child_Time_Falling_Asleep_NightPX091502240000How long does it take your child to fall asleep at night? (a guess is O.K.)4N/A
PX091502_Child_Bedtime_Difficult_Routines_RitualsPX091502250000At bedtime does your child usually have difficult "routines" or "rituals," argue a lot, or otherwise behave badly?4N/A
PX091502_Child_Bang_Head_Rock_BodyPX091502260100DOES YOUR CHILD bang his or her head or rock his or her body when going to sleep?4N/A
PX091502_Child_Wake_Multiple_Times_NightPX091502260200DOES YOUR CHILD wake up more than twice a night on average?4N/A
PX091502_Child_Trouble_Back_Asleep_NightPX091502260300DOES YOUR CHILD have trouble falling back asleep if he or she wakes up at night?4N/A
PX091502_Child_Trouble_Back_Asleep_MorningPX091502260400DOES YOUR CHILD wake up early in the morning and have difficulty going back to sleep?4N/A
PX091502_Child_Bedtime_Change_A_LotPX091502270000Does the time at which your child goes to bed change a lot from day to day?4N/A
PX091502_Child_Get_Up_Change_A_LotPX091502280000Does the time at which your child gets up from bed change a lot from day to day?4N/A
PX091502_Time_Child_Bed_WeekdayPX091502290100WHAT TIME DOES YOUR CHILD USUALLY go to bed during the week?4N/A
PX091502_Time_Child_Bed_Weekend_VacationPX091502290200WHAT TIME DOES YOUR CHILD USUALLY go to bed on the weekend or vacation?4N/A
PX091502_Time_Child_Get_Up_WeekdayPX091502290300WHAT TIME DOES YOUR CHILD USUALLY get out of bed on weekday mornings?4N/A
PX091502_Time_Child_Get_Up_Weekend_VacationPX091502290400WHAT TIME DOES YOUR CHILD USUALLY get out of bed on weekend or vacation mornings?4N/A
PX091502_Child_Wake_Up_Unrefreshed_MorningPX091502300100DOES YOUR CHILD wake up feeling unrefreshed in the morning?4N/A
PX091502_Child_Sleepiness_Problem_DayPX091502300200DOES YOUR CHILD have a problem with sleepiness during the day?4N/A
PX091502_Child_Feel_Sleepy_DayPX091502300300DOES YOUR CHILD complain that he or she feels sleepy during the day?4N/A
PX091502_Child_Appear_Sleepy_DayPX091502310000Has a teacher or other supervisor commented that your child appears sleepy during the day?4N/A
PX091502_Child_Usually_Nap_DayPX091502320000Does your child usually take a nap during the day?4N/A
PX091502_Child_Hard_Wake_Up_MorningPX091502330000Is it hard to wake your child up in the morning?4N/A
PX091502_Child_Wake_Up_Headache_MorningPX091502340000Does your child wake up with headaches in the morning?4N/A
PX091502_Child_Headache_More_Once_MonthPX091502350000Does your child get a headache at least once a month, on average?4N/A
PX091502_Child_Stop_Growing_Normal_RatePX091502360100Did your child stop growing at a normal rate at any time since birth?4N/A
PX091502_Child_Tonsils_RemovePX091502370100Does your child still have tonsils?4N/A
PX091502_Child_Tonsils_Remove_DatePX091502370200When were they removed?4N/A
PX091502_Child_Tonsils_Remove_ReasonPX091502370300Why were they removed?4N/A
PX091502_Child_Condition_Difficulty_Breathing_EverPX091502380101HAS YOUR CHILD EVER had a condition causing difficulty with breathing?4N/A
PX091502_Child_Surgery_EverPX091502380201HAS YOUR CHILD EVER had surgery?4N/A
PX091502_Child_Difficulty_Breathing_Occur_SurgeryPX091502380202Did any difficulties with breathing occur before, during, or after surgery?4N/A
PX091502_Child_Sudden_Weak_Legs_EverPX091502380300HAS YOUR CHILD EVER become suddenly weak in the legs, or anywhere else, after laughing or being surprised by something?4N/A
PX091502_Child_Unable_Move_Able_Look_EverPX091502380400HAS YOUR CHILD EVER felt unable to move for a short period, in bed, though awake and able to look around?4N/A
PX091502_Child_Irresistible_Urge_NapPX091502390000Has your child felt an irresistible urge to take a nap at times, forcing him or her to stop what he or she is doing in order to sleep?4N/A
PX091502_Child_Sense_Dreaming_Awake_EverPX091502400000Has your child ever sensed that he or she was dreaming (seeing images or hearing sounds) while still awake?4N/A
PX091502_Child_Caffeinated_BeveragePX091502410100Does your child drink caffeinated beverages on a typical day (cola, tea, coffee)?4N/A
PX091502_Child_Caffeinated_Beverage_QuantityPX091502410200How many cups or cans per day?4N/A
PX091502_Child_Use_Recreational_DrugPX091502420100Does your child use any recreational drugs?4N/A
PX091502_Child_Use_Recreational_Drug_ListPX091502420200Which recreational drugs does your child use?4N/A
PX091502_Child_Use_Recreational_Drug_FrequencyPX091502420300How often does your child use recreational drugs?4N/A
PX091502_Child_Use_Cigarette_TobaccoPX091502430100Does your child use cigarettes, smokeless tobacco, snuff, or other tobacco products?4N/A
PX091502_Child_Use_Cigarette_Tobacco_ListPX091502430200Which tobacco products does your child use?4N/A
PX091502_Child_Use_Cigarette_Tobacco_FrequencyPX091502430300How often does your child use cigarettes, smokeless tobacco, snuff, or other tobacco products?4N/A
PX091502_Child_OverweightPX091502440100Is your child overweight?4N/A
PX091502_Child_Overweight_First_AgePX091502440200At what age did this first develop?4N/A
PX091502_Child_High_Arched_Palate_Roof_MouthPX091502450000Has a doctor ever told you that your child has a high-arched palate (roof of the mouth)?4N/A
PX091502_Child_Take_Ritalin_EverPX091502460000Has your child ever taken Ritalin (methylphenidate) for behavioral problems?4N/A
PX091502_Child_ADD_ADHD_EverPX091502470000Has a health professional ever said that your child has attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD)?4N/A
PX091502_Child_Medical_ProblemPX091502480000If you are currently at a clinic with your child to see a physician, what is the problem that brought you?4N/A
PX091502_Child_Long_Term_Medical_Problem_1PX091502490100If your child has long-term medical problems, please list the three you think are most significant.4N/A
PX091502_Child_Long_Term_Medical_Problem_2PX091502490200If your child has long-term medical problems, please list the three you think are most significant.4N/A
PX091502_Child_Long_Term_Medical_Problem_3PX091502490300If your child has long-term medical problems, please list the three you think are most significant.4N/A
PX091502_Child_Current_Medication_Medicine_1PX091502500101Please list any medications your child currently takes: Medicine.4N/A
PX091502_Child_Current_Medication_Dose_1PX091502500102Please list any medications your child currently takes: Size (mg) or amount per dose.4N/A
PX091502_Child_Current_Medication_Frequency_Taken_1PX091502500103Please list any medications your child currently takes: Taken how often?4N/A
PX091502_Child_Current_Medication_Date_Taken_1PX091502500104Please list any medications your child currently takes: Dates Taken.4N/A
PX091502_Child_Current_Medication_Effect_1PX091502500105Please list any medications your child currently takes: Effect.4N/A
PX091502_Child_Current_Medication_Medicine_2PX091502500201Please list any medications your child currently takes: Medicine.4N/A
PX091502_Child_Current_Medication_Dose_2PX091502500202Please list any medications your child currently takes: Size (mg) or amount per dose.4N/A
PX091502_Child_Current_Medication_Frequency_Taken_2PX091502500203Please list any medications your child currently takes: Taken how often?4N/A
PX091502_Child_Current_Medication_Date_Taken_2PX091502500204Please list any medications your child currently takes: Dates Taken.4N/A
PX091502_Child_Current_Medication_Effect_2PX091502500205Please list any medications your child currently takes: Effect.4N/A
PX091502_Child_Current_Medication_Medicine_3PX091502500301Please list any medications your child currently takes: Medicine.4N/A
PX091502_Child_Current_Medication_Dose_3PX091502500302Please list any medications your child currently takes: Size (mg) or amount per dose.4N/A
PX091502_Child_Current_Medication_Frequency_Taken_3PX091502500303Please list any medications your child currently takes: Taken how often?4N/A
PX091502_Child_Current_Medication_Date_Taken_3PX091502500304Please list any medications your child currently takes: Dates Taken.4N/A
PX091502_Child_Current_Medication_Effect_3PX091502500305Please list any medications your child currently takes: Effect.4N/A
PX091502_Child_Current_Medication_Medicine_4PX091502500401Please list any medications your child currently takes: Medicine.4N/A
PX091502_Child_Current_Medication_Dose_4PX091502500402Please list any medications your child currently takes: Size (mg) or amount per dose.4N/A
PX091502_Child_Current_Medication_Frequency_Taken_4PX091502500403Please list any medications your child currently takes: Taken how often?4N/A
PX091502_Child_Current_Medication_Date_Taken_4PX091502500404Please list any medications your child currently takes: Dates Taken.4N/A
PX091502_Child_Current_Medication_Effect_4PX091502500405Please list any medications your child currently takes: Effect.4N/A
PX091502_Child_Past_Medication_Medicine_1PX091502510101Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Medicine.4N/A
PX091502_Child_Past_Medication_Dose_1PX091502510102Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Size (mg) or amount per dose.4N/A
PX091502_Child_Past_Medication_Frequency_Taken_1PX091502510103Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Taken how often?4N/A
PX091502_Child_Past_Medication_Date_Taken_1PX091502510104Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Dates Taken.4N/A
PX091502_Child_Past_Medication_Effect_1PX091502510105Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Effect.4N/A
PX091502_Child_Past_Medication_Medicine_2PX091502510201Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Medicine.4N/A
PX091502_Child_Past_Medication_Dose_2PX091502510202Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Size (mg) or amount per dose.4N/A
PX091502_Child_Past_Medication_Frequency_Taken_2PX091502510203Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Taken how often?4N/A
PX091502_Child_Past_Medication_Date_Taken_2PX091502510204Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Dates Taken.4N/A
PX091502_Child_Past_Medication_Effect_2PX091502510205Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Effect.4N/A
PX091502_Child_Past_Medication_Medicine_3PX091502510301Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Medicine.4N/A
PX091502_Child_Past_Medication_Dose_3PX091502510302Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Size (mg) or amount per dose.4N/A
PX091502_Child_Past_Medication_Frequency_Taken_3PX091502510303Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Taken how often?4N/A
PX091502_Child_Past_Medication_Date_Taken_3PX091502510304Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Dates Taken.4N/A
PX091502_Child_Past_Medication_Effect_3PX091502510305Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Effect.4N/A
PX091502_Child_Past_Medication_Medicine_4PX091502510401Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Medicine.4N/A
PX091502_Child_Past_Medication_Dose_4PX091502510402Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Size (mg) or amount per dose.4N/A
PX091502_Child_Past_Medication_Frequency_Taken_4PX091502510403Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Taken how often?4N/A
PX091502_Child_Past_Medication_Date_Taken_4PX091502510404Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Dates Taken.4N/A
PX091502_Child_Past_Medication_Effect_4PX091502510405Please list any medication your child has taken in the past if the purpose of the medication was to improve his or her behavior, attention, or sleep: Effect.4N/A
PX091502_Child_Sleep_Disorder_Diagnosis_1PX091502520101Please list any sleep disorders diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Sleep_Disorder_Start_Date_1PX091502520102The date the sleep disorder started?4N/A
PX091502_Child_Sleep_Disorder_Still_Present_1PX091502520103Is the sleep disorder still present?4N/A
PX091502_Child_Sleep_Disorder_Diagnosis_2PX091502520201Please list any sleep disorders diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Sleep_Disorder_Start_Date_2PX091502520202The date the sleep disorder started?4N/A
PX091502_Child_Sleep_Disorder_Still_Present_2PX091502520203Is the sleep disorder still present?4N/A
PX091502_Child_Sleep_Disorder_Diagnosis_3PX091502520301Please list any sleep disorders diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Sleep_Disorder_Start_Date_3PX091502520302The date the sleep disorder started?4N/A
PX091502_Child_Sleep_Disorder_Still_Present_3PX091502520303Is the sleep disorder still present?4N/A
PX091502_Child_Sleep_Disorder_Diagnosis_4PX091502520401Please list any sleep disorders diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Sleep_Disorder_Start_Date_4PX091502520402The date the sleep disorder started?4N/A
PX091502_Child_Sleep_Disorder_Still_Present_4PX091502520403Is the sleep disorder still present?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Diagnosis_1PX091502530101Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Start_Date_1PX091502530102The date the psychological, psychiatric, emotional, or behavioral problem started?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Still_Present_1PX091502530103Is the psychological, psychiatric, emotional, or behavioral problem still present?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Diagnosis_2PX091502530201Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Start_Date_2PX091502530202The date the psychological, psychiatric, emotional, or behavioral problem started?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Still_Present_2PX091502530203Is the psychological, psychiatric, emotional, or behavioral problem still present?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Diagnosis_3PX091502530301Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Start_Date_3PX091502530302The date the psychological, psychiatric, emotional, or behavioral problem started?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Still_Present_3PX091502530303Is the psychological, psychiatric, emotional, or behavioral problem still present?4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Diagnosis_4PX091502530401Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or suspected by a physician in your child.4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Start_Date_4PX091502530402The date the psychological, psychiatric, emotional, or behavioral problem started?4N/A
PX091502_Sleep_Behavior_Disorder_Relative_1PX091502540101Please list any sleep or behavior disorders diagnosed or suspected in your child's brothers, sisters, or parents: Relative.4N/A
PX091502_Sleep_Behavior_Disorder_Condition_1PX091502540102Please list any sleep or behavior disorders diagnosed or suspected in your child's brothers, sisters, or parents: Condition.4N/A
PX091502_Sleep_Behavior_Disorder_Relative_2PX091502540201Please list any sleep or behavior disorders diagnosed or suspected in your child's brothers, sisters, or parents: Relative.4N/A
PX091502_Sleep_Behavior_Disorder_Condition_2PX091502540202Please list any sleep or behavior disorders diagnosed or suspected in your child's brothers, sisters, or parents: Condition.4N/A
PX091502_Sleep_Behavior_Disorder_Relative_3PX091502540301Please list any sleep or behavior disorders diagnosed or suspected in your child's brothers, sisters, or parents: Relative.4N/A
PX091502_Sleep_Behavior_Disorder_Condition_3PX091502540302Please list any sleep or behavior disorders diagnosed or suspected in your child's brothers, sisters, or parents: Condition.4N/A
PX091502_Additional_CommentsPX091502550000Please print any additional comments you feel are important. Please also describe details regarding any of the above questions.4N/A
PX091502_Child_Not_Seem_ListenPX091502560100This child often does not seem to listen when spoken to directly.4N/A
PX091502_Child_Difficulty_OrganizingPX091502560200This child often has difficulty organizing tasks and activities.4N/A
PX091502_Child_Easily_DistractedPX091502560300This child often is easily distracted by extraneous stimuli.4N/A
PX091502_Child_Fidget_Hands_Feet_SquirmPX091502560400This child often fidgets with hands or feet or squirms in seat.4N/A
PX091502_Child_On_Go_Driven_By_MotorPX091502560500This child often is "on the go" or often acts as if "driven by a motor".4N/A
PX091502_Child_Interrupt_Intrude_OthersPX091502560600This child often interrupts or intrudes on others (e.g., butts into conversations or games.)4N/A
PX091502_Child_Psychological_Psychiatric_Behavior_Still_Present_4PX091502530403Is the psychological, psychiatric, emotional, or behavioral problem still present?4N/A