Questionnaires

Physician Report Authorization

Name

Date

I hereby give permission for the reports of my Sleep Studies and Office consultation and visits to be sent to the following physicians. REPORTS CANNOT BE SENT WITHOUT COMPLETE NAMES AND ADDRESSES, INCLUDING ZIP CODE.

Family Physician

Name

Address

City

State

Zip

Referring Physician

Name

Address

City

State

Zip

Additional Report

Name

Address

City

State

Zip

Signature

Date

Registration

Name

Age

Height

Weight

Address

Phone

Primary Physician

Past Medical History

Present Medication and Dosage

(please enlist prescription as well as over the counter)

Allergies

Do you have any drug allergies?

Yes No

Please Describe

Personal History

Have you ever regularly smoked?

Yes No

If yes, how many years?

If yes, are you still smoking?

How many cigarettes did you or do you smoke in an average day?

How often on the average do you consume alcoholic beverages?

Once a month or less 2-3 times a week Nearly Everyday

How many caffeinated beverages do you use in a day?

General

What is your main problem regarding sleep, please describe

How long have you had the sleep problem?

Assessing Sleepiness

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling 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 wok out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

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 cirumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

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

Do you feel refreshed in the morning after a usual night sleep?

Yes No

Does sleepiness interfere with your activities during the day?

Yes No

If yes, please describe

How often do you have problem throughout the day due to tiredness and fatigue?

Never Occasionally Frequently Almost Always

Pertaining to Snoring and Sleep Apnea

Do you Snore?

Yes No

Do people complain that you snore?

Yes No

Do you episodically stop breathing when you are sleeping?

Yes No

When you snore, it is usually:

Barely audible

Easily hear in the bedroom

Disturbs my bed partner

Heard even outside the bedroom

Altogether, how many years have you snored?

0-1 years 2-5 years 5-10 years 10 or more years

How often do you awaken with choking or a sensation of not breathing?

Never Occasionally Frequently Almost always

Have you gained more than 5 pounds in the last year?

Yes No

How much weight have you gained in the last 5 years?

Do you mostly sleep on your:

Back Side Stomach

Have you been in a traffic accident or near miss in the last 5 years?

Yes No

Pertaining to Insomnia

How often do you experience any problems falling asleep?

Never Occasionally Frequently Almost always

If you are experiencing problems falling asleep, how long have you had that?

How long does it take you on an average night to fall asleep?

How and when did your insomnia problems start?

How many hours do you sleep on average in 24 hours?

What is your usual time of sleep during the weekdays?

What is your usual time of sleep on weekends?

How many long naps do you take during the day?

How many times during the night do you go to the bathroom to urinate?

0-1 2-3 3-4 5 or more

How often do you have trouble staying asleep?

Never Occasionally Frequently Almost always

Do you wake up early in the morning without a desire to do anything?

Never Occasionally Frequently Almost always

How much caffeine do you consume in the form of coffee, tea or cola drinks?

Pertaining to Narcolepsy

Review of Systems

Family History

Is there a family history of sleep apnea or narcolepsy?

Yes No

Is there a family history of any heart of lung problems?

Yes No

Is there a family history of any other disease?

Yes No

Is yes to any of the above years, please describe

Questions for the Bed Partner

Does your partner snore?

Yes No

Does your partner seem to stop breathing during sleep?

Yes No

Does your seep partner jerk his or her limbs in sleep?

Yes No

Please include any other information that may be helpful

Your information will be encrypted.