Sleep Questionnaire

A good sleep is important to your well-being. Since most people spend roughly 1/3 of their lives asleep, it is easy to see how the quality of sleep directly affects the quality of your life. One in 3 Americans has a sleep disorder making sleep/waking hours miserable. Many of these people suffer needlessly because they are unaware that a problem exists. Once detected, most sleep disorders can be corrected. If you have experienced any of the following symptoms in the last year, check the box YES. When referring to night, assume that this means during your sleep period.

Patient Name

Date of Birth

Section 1:

I have difficulty falling asleep.

Yes No

Thoughts race through my mind and this prevents me from sleeping.

Yes No

I feel afraid to go to sleep.

Yes No

I wake up during the night and have trouble falling back asleep.

Yes No

I worry about things and have trouble relaxing.

Yes No

I wake up earlier in the morning than I would like.

Yes No

I lie awake for 30 minutes or more before I fall asleep.

Yes No

I feel sad and depressed.

Yes No

Section 2:

I have been told that I snore.

Yes No

I have been told that I stop breathing sometimes when I sleep.

Yes No

I have been told my blood pressure is high.

Yes No

I have been told by friend/family that my personality has changed.

Yes No

I am gaining weight.

Yes No

I feel that I sweat more than I should at night.

Yes No

I have noticed my heart pounding during the night.

Yes No

I get morning headaches.

Yes No

I have trouble sleeping when I have a cold.

Yes No

I wake up suddenly some nights gasping for breath.

Yes No

I am overweight.

Yes No

I am losing my sex drive.

Yes No

I feel sleepy during the day even when I sleep through the night.

Yes No

Section 3:

I have a chronic cough.

Yes No

I have to use antacids (Tums, Alka-Seltzer, etc) at least once a week.

Yes No

I have morning hoarseness or get sore throats.

Yes No

I wake up at night coughing or wheezing.

Yes No

I wake up at night needing to catch my breath or with chest pain.

Yes No

Section 4:

I have had trouble concentrating in school/work.

Yes No

When I am angry or surprised, I feel like I’m going limp.

Yes No

I have fallen asleep while driving.

Yes No

I feel like I go around in a daze.

Yes No

I have experienced vivid dream-like scenes upon falling asleep/waking.

Yes No

I have fallen asleep during physical effort.

Yes No

I feel like I am hallucinating when I fall asleep.

Yes No

I like to cram a full day into every hour to get everything done.

Yes No

I have fallen asleep when laughing or crying.

Yes No

No matter how hard I try to stay awake, I fall asleep anyway.

Yes No

I sometimes feel like I am unable to move waking up or falling asleep.

Yes No

Section 5:

Other than when exercising, I will experience muscle tension in my legs.

Yes No

I have noticed (or others comment that parts of my body jerk.

Yes No

I have been told that I kick at night.

Yes No

I experience aching/”crawling” sensations in my legs.

Yes No

I experience leg pain during the night.

Yes No

Sometimes I can’t keep my legs still at night; I just have to move.

Yes No

I awaken with sore or achy muscles.

Yes No

Questions about your habits:

Weekday: Bedtime

Weekday: Wakeup

Weekday: Nap

Weekend: Bedtime

Weekend: Wakeup

Weekend: Nap

Work hours

Shift Work?

Yes No

Type of work

Please provide information for the following procedures:

CHEST XRAY/CT in the last year

Yes No

If yes, where?

Pulmonary Function/6 minute walk

Yes No

If yes, where?

Sleep studies (home or in lab)

Yes No

If yes, where?

Are you currently using CPAP/BIPAP?

If yes, bring your compliance card/PAP machine to the office

Do you work with a durable medical equipment (DME) company

Family medical information

If Unknown Adopted

Parents: Mother

Parents: Father

Siblings: Sisters #

Siblings: Brothers #

Children: Daughter's #

Children: Son's #

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