New Patient Questionnaire

Accredited by the American Academy of Sleep Medicine

Legal First & Last Name

Date of Birth

Phone

Height

Weight

INSURANCE CARD FRONT AND BACK ARE REQUIRED. Please upload a copy of your current insurance cards. Reporting any secondary insurance is required.

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PHOTO ID FRONT AND BACK ARE REQUIRED. Please upload a copy of your current photo ID.

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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:

What is the main reason for your visit?

Have you seen a physician before about your sleep or alertness problem?

Yes No

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

Add new row

Have you had a previous sleep test?

Yes No

If Yes, when and where:

When:

Where:

Have you ever been diagnosed with any of the following sleep disorder(s)?

Sleep apnea

Restless leg syndrome

Narcolepsy

Other

If other, please specify.

Work

Occupation

Do you work shift work?

Yes No

If retired, previous occupation:

Typical work schedule:

Do you work with hazardous material or heavy machinery?

Yes No

Do you have a commercial driver’s license (truck, bus, etc.) or pilot’s license?

Yes No

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

How many times do you usually wake up out of sleep, even if just momentarily?

Once you awaken during the night, how long does it typically take to fall back asleep?

< 15 minutes 15–30 minutes 30–60 minutes 1+ hours

How many hours of sleep per night do you estimate that you usually get?

Do you nap?

Yes No

If Yes, how frequently do you nap?

How long are your naps?

Do you feel more refreshed after your naps?

Yes No

Do you consider yourself a:

Morning person/“Early Bird” Evening person/“Night Owl” Neither

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?

Do you use pills (prescription or over-the-counter) or other substances to help you sleep?

Yes No

If Yes, please describe:

Do you use alcohol or other controlled substances to help you sleep?

Yes No

What body positions do you sleep in? Check all that apply.

On my back

On my stomach

On my sides

In a recliner

With the head of the bed elevated

Do you have a bed partner?

Yes No

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?

Do you awaken from sleep for urination?

Yes No

If Yes, how often?

Times/Night

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?

Yes No

Do you have any history of orthodontic treatment (such as braces)?

Yes No

Have you had any weight changes over the past few years to 5 years?

Yes No

Enter pounds gained OR pounds lost. Please do not fill in both boxes.

Pounds gained:

Pounds lost:

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?

Do you use coffee, caffeine drinks, or stimulants to stay alert?

Do you feel sleepy when driving?

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

Yes No

Have you been injured because of fatigue or sleepiness?

Yes No

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?

Have you been told, as an adult, that you sleepwalk or have awoken with periods of confusion or disorientation during the night?

Yes No

Do you act out dreams (with vigorous arm or leg movements) during sleep?

Yes No

Do you have frequent or repetitive frightening dreams or nightmares?

Yes No

Have you wet the bed during sleep as an adult?

Yes No

Do you have a history of seizures during sleep?

Yes No

Have you heard voices or seen visions as you drift into or awaken from sleep?

Yes No

Do you awaken from sleep unable to move or speak (as if you are paralyzed), yet you feel like you are awake?

Yes No

Do you have attacks of physical weakness (actual loss of muscle control) when laughing or crying, or during other emotional situations?

Yes No

Medical History

Please check all that apply to you.

None

If selected other, please list below.

Surgical History

Please check all that apply to you.

No previous surgeries

If selected other, please list below.

Social History

Do drink caffeinated beverages? If yes, how many servings?

Day

Week

Do you drink caffeine within 6 hours of going to bed?

Yes No

Do you exercise?

Yes No

If yes, what type of exercise and how frequently?

Do you use tobacco products?

Yes No

Cigarettes

Vape

Cigars

Pipe

Chew

If yes, how many packs or cans per day and for how long?

If no, have you ever smoked?

Yes No

If yes, when did you quit?

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

Do you drink alcohol?

Yes No

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

Do you use recreational drugs?

Yes No

If yes, which types and how often per week?

Family History

Family history unknown

No family history of sleep or cardiovascular disorders

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

Mother

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

Father

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

Sister

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

Brother

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

Daughter

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

Son

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

Other

Sleep Apnea

Suspected Sleep Apnea

Insomnia

Restless Leg Syndrome

Narcolepsy

High Blood Pressure

Heart Disease

Stroke

If other, please specify relationship.

Medications

Name of and location of preferred pharmacy:

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

Add new row

Do you have allergies to any medications or substances (e.g., latex)?

Yes No

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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