Pacific Sleep Program
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:
If Yes, when and where:
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 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?
Do you have any history of orthodontic treatment (such as braces)?
Have you had any weight changes over the past few years to 5 years?
Enter pounds gained OR pounds lost. Please do not fill in both boxes.
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?
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?
Please check all that apply to you.
Please check all that apply to you.
If yes, how many alcoholic drinks do you have during the week?
If yes, which types and how often per week?
If you didn’t check either box above, please complete below.
Please list all of your current medications and dosages, including non-prescription medications.
If Yes, please list each medication or substance you are allergic to and explain how you react to it below:
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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