Sleep History Questionnaire

Sleep Medicine Consultants

Name

Date of Birth

Telephone Number (no spaces or dashes)

Age (no spaces or dashes)

Referring Physician

Email Address

Height

Weight

Sleep History

Describe in detail what your sleep problem is and how long this has been a problem:

Have you ever been diagnosed or treated for sleep apnea, insomnia, or any other sleep disorder?

Yes No

If Yes please explain

What time do you go to bed?

How long does it take you to fall asleep?

How many times do you awaken after falling asleep?

Check the reasons for waking up

Need to urinate

Shortness of breath

Palpitations

Anxiety

Other

Describe your snoring

Light Occasional Constant Heavy/Loud Other

While sleeping, have you ever been observed to stop breathing, choke or gasp for air?

Yes

What time do you awaken in the mornings

How do you feel in the morning upon wakening?

Refreshed

Groggy

Sleepy

Unrefreshed

Other

Do you ever awaken with the following (check all that apply)

Headaches

Chest Pain

Heartburn

Dry Mouth

Nasal Congestion

Do you take naps during the day?

Yes No

If Yes, How often?

Do you feel refreshed upon awakening from these naps?

Yes No

Are you now or have you ever been in the care of a Cardiologist?

Yes No

Have you had recent weight gain or loss?

Gain Loss

How much weight and in what length of time?

Are you currently using a CPAP OR BIPAP machine?

Yes No

Where do you get your supplies?

Do you use insurance to pay for your supplies?

Epworth Sleepiness Scale

0=would NEVER doze 1=Slight chance of dozing 2=moderate chance of dozing 3=high chance of dozing

Please rate the chance of you dozing off in the following situations

Sitting and reading

Watching TV

Sitting inactive in a public place

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

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch with no alcohol

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

Add all the numbers together for a total

Do you have gas, indigestion or heartburn at night?

Yes No

Do you have night sweats?

Yes No

Do your legs kick and twitch frequently during the night?

Yes No

Do you have restless legs ?

Yes No

Problems with impotence or lack of sexual drive?

Yes No

Do you have problems with memory or concentration?

Yes No

Are you irritable or short tempered ?

Yes No

Do you feel depressed or disinterested in things ?

Yes No

Do you grind your teeth at night?

Yes No

Have you ever had near misses, motor vehicle accident or fallen asleep when driving ?

Yes No

Do you have frequent uncontrollable bouts of sleep, sleep attacks, or an irresistible urge to sleep?

Yes No

When you awaken from sleep, do you ever feel paralyzed, unable to move even though you are awake?

Yes No

While in the process of falling asleep do you have vivid dreams or hallucinations ?

Yes No

When someone startles you or makes you laugh do your limbs/neck get weak or do you fall?

Yes No

Social History

Marital Status

Single Married Domestic Partner Widowed

What is your present occupation?

What hours do you work?

Have you ever smoked?

Yes No

How many years

How many packs per day?

Have you quit smoking?

Yes No

How long ago did you quit?

Do you drink caffeinated beverages ?

Yes No

If yes, how many drinks per day

Do you drink alcoholic beverages?

Yes No

If Yes, how often ?

Do you get regular exercise?

Yes No

If Yes how often do you exercise?

Do you have any family members with sleep problems? Please describe:

Thank you for taking the time to complete the forms. We appreciate your help getting us this information.

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