Pacific Sleep Program

New Patient Questionnaire

Please correct the errors described below.
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    The Epworth Sleepiness Scale

    How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, give a general estimate for each situation.

    0: NEVER doze

    1: SLIGHT chance of dozing

    2: MODERATE chance of dozing

    3: HIGH chance of dozing


    Chance of dozing (0–3)

    Sitting and reading

    Watching TV

    Sitting, inactive in a public place (e.g., a theater or a meeting)

    As a passenger in a car for an hour without a break

    Lying down to rest in the afternoon when the circumstances permit

    Sitting and talking to someone

    Sitting quietly after lunch without alcohol

    In a car, while stopped for a few minutes in traffic


    Please answer the following questions to the best of your ability:

    Please list the physicians who should receive a copy of your sleep study results:

    Add new row

    If Yes, when and where:

    Work

    Sleep Patterns

    Please complete the following questions about your sleep patterns as best you can. You may, if you wish, have a bed partner or family member complete this section with you.

    Bed Time

    Rise Time

    How long it takes you to fall asleep

    Typical sleep schedule on work days

    Typical sleep schedule on days off

    If Yes, how frequently do you nap?


    Please answer the following questions by placing an “X” under the option that best fits.

    Seldom/ never

    Sometimes

    Usually/ always

    Do you feel like your sleep is unrefreshing?

    Is your sleep area cool, dark, and quiet?

    Are you bothered by outside lights or noises when you sleep?

    Do you watch TV or use electronic devices (computer, tablets, etc.) before bed?

    Do you lie awake at night feeling worried or depressed or with your mind “racing”?

    Do pain issues disturb your sleep?

    If Yes, please describe:

    If Yes, please answer the following questions by placing an “X” under the option that best fits:

    Seldom/ never

    Sometimes

    Usually/ always

    Does your bed partner “elbow” you to change positions during sleep?

    Does your bed partner use earplugs or leave the room due to your snoring?

    Please answer the following questions by placing an “X” under the option that best fits.

    Seldom/ never

    Sometimes

    Usually/ always

    Have you been told (by anyone) that you snore?

    Have you been told that you snore loudly and bother others?

    Have you been told that you appear to stop breathing during sleep?

    Are you aware of choking or gasping awake during sleep?

    Do you awaken with your mouth or throat dry and irritated?

    Do you have bothersome nasal congestion during sleep?

    If Yes, how often?

    Please answer the following questions by placing an “X” under the option that best fits

    Seldom/ never

    Sometimes

    Usually/ always

    Do you awaken from sleep for heartburn (reflux or GERD)?

    Do you awaken from sleep with night sweats?

    Do you awaken from sleep with a headache?

    Do you awaken from sleep with chest pain or your heart racing?

    Are you aware of grinding your teeth during sleep, or has a dentist told you that you do this?

    If Yes, do you wear a night guard?

    Have you had any weight changes over the past few years?

    If yes, please describe

    Do you exercise?

    If yes, what type and how often?

    Are you drowsy or sleepy during your regular awake hours?

    Do you have problems with memory or concentration?

    Lately, have you felt more depressed or more anxious?

    Have you been injured because of fatigue or sleepiness?

    Do you feel sleepy when driving?

    Have you had any driving accidents or “close calls” due to fatigue?

    Do you experience persistent, uncomfortable feelings in your legs and/or arms while sitting or lying down?

    Do unpleasant feelings in your legs make it difficult for you to get to sleep or awaken you at night?

    Do you twitch or make sudden jerking movements during sleep?

    Do you awaken yourself or your bed partner by kicking during sleep?

    Medical History

    Please check all that apply to you.

    Surgical History

    Please check all that apply to you.

    Family History

    If you didn’t check either box, please complete below.

    Social History

    (If you can’t remember the exact date, give your best approximation)

    If yes, how many alcoholic drinks do you have during the week?

    If yes, which types and how often per week?

    In a usual 24-hour period

    Within 6 hours of going to bed

    I don’t drink this caffeinated beverage

    Caffeinated coffee

    Caffeinated tea

    Caffeinated soda or pop

    Caffeinated energy drinks

    Medications

    Please list all of your current medications and dosages, including non-prescription medications.

    Add new row

    If Yes, please list each medication or substance you are allergic to and explain how you react to it below:

    Add new row

    Thank you for completing the form. The information has been routed in a secure, HIPAA-compliant manner to Pacific Sleep Program in anticipation of your upcoming appointment.

    If you have any questions, please contact us at (503) 228-4414. We look forward to seeing you at your appointment!

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