Have you ever been hospitalized for psychiatric care? Please list and describe.
Have you ever been treated with any of the following medications? Circle all that apply and list any good or bad effects of the medications.
Please list all medications you are currently taking, including over-the-counter medications, herbals, and supplements.
How often have you used the following substances?
Marijuana or K2/"spice"
Opiates (e.g. Heroin, morphine, Percocet, 5 oxycodone, Tylenol #3, Dilaudid/hydromorphone)
Tranquilizers/sedatives (e.g. Xanax, Ativan, Klonopin, Valium)
PCP or LSD
Please list blood relatives who have been diagnosed with the following conditions.
Over the last 2 weeks. how often have you been bothered by any of the following problems?
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545. Permission for single-use of the information contained in this material was obtained from the Associated Professional Sleep Societies, LLC, September 2006.
Copyright © MW Johns 1990-1997. Used under license.
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