ALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT QUESTIONNAIRE/HISTORY PLEASE COMPLETE AND BRING WITH YOU ON THE NIGHT OF YOUR TEST.

Transcription

1 ALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT QUESTIONNAIRE/HISTORY PLEASE COMPLETE AND BRING WITH YOU ON THE NIGHT OF YOUR TEST. NAME DATE: HEIGHT: WEIGHT: DOB: SEX: HOME PHONE #: REFERRING PHYSICIAN: FAMILY PHYSICIAN: PLEASE LIST ALL MEDICATIONS: (INCLUDING ALL OVER THE COUNTER/VITAMINS/SUPPLEMENTS & HERBS WITH DOSAGES & HOW OFTEN YOU TAKE YOUR MEDICATION) DO YOU HAVE ANY ALLERGIES TO MEDICATIONS/FOOD/TAPE? YES NO IF YES, PLEASE LIST: PLEASE LIST YOUR MEDICAL HISTORY/HOSPITALIZATIONS:

2 Please circle Yes or No for each question: ALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT HISTORY PAGE 2 SLEEP HISTORY: 1. I have been told that I snore. Yes No 2. I have been told that I intermittently quit breathing during the night. Yes No 3. I often wake up gasping at night. Yes No 4. I feel tired or sleepy during the day. Yes No 5. I occasionally or frequently sweat at night Yes No 6. Do you wake up with morning headaches? Yes No 7. Do you feel refreshed in the morning after sleeping all night? Yes No 8. Do you sleep on your back? Yes No 9. Do you awaken with a dry mouth? Yes No 10. Does your legs kick or move during sleep? Yes No 11. Are you a shift worker? (Works Midnights) Yes No 12. Are you excessively sleepy during the day? Yes No 13. Do you fall asleep at inappropriate times? Yes No 14. Do you have vivid dreams? Yes No 15. Have you ever acted out your dreams? (screaming, punching,etc) Yes No 16. I have trouble falling asleep at night. Yes No 17. Do you take sleeping medications to fall asleep? Yes No 18. Do you take naps during the day? Yes No 19. Have you been told you walk in your sleep? Yes No 20. Have you been told you talk in your sleep? Yes No 21. Do you grind your teeth at night? (During sleep) Yes No 22. Have you ever fallen asleep while driving? Yes No 23. Do you frequently use the restroom during the night? Yes No 24. Do you smoke? Yes No If yes, how much? How many years have you smoked? years 25. Do you drink alcohol? Yes No If yes, check one of the following: Daily Weekends Occasionally/Socially 26. Are you a Diabetic? Yes No 27. Do you have High Blood Pressure? Yes No 28. Do you have a history of seizures/convulsions? Yes No 29. Do you have any special needs that would need taken care of during your test? Yes No If yes, please describe:

3 How likely are you to doze or fall asleep in certain situations? Please check one box that is most appropriate to you. Sitting & Reading Watching TV Sitting in a Movie Riding in a car Sitting & Talking After Meals At Work Driving BURNS ANXIETY QUESTIONNAIRE Instructions: The symptoms of anxiety can be divided into those affecting feelings, thoughts and the body. To find out the level of your anxiety, please circle the number that best describes how much the symptoms or problems that have affected you during the past week. 0-Not at all 1-Somewhat 2-Moderately 3-A lot Category 1: Anxious Feelings Anxiety, nervousness, worries or fear Feelings that things around you are strange, unreal or foggy Feeling detached from all or part of your body Sudden, unexpected panic spells Apprehension or a sense of impending doom Feeling tense, stressed, uptight or on edge Category 2: Anxious Thoughts Difficulty Concentrating Racing thoughts or having your mind jump from one thing to another Frightening fantasies or daydreams Feeling that you re on the verge of losing control Fears of cracking up or going crazy Fears of fainting or passing out Fears of physical illness Concerns about looking foolish or inadequate in front of others Fears of being along, isolated or abandoned Fears of criticism or disapproval Fears that something terrible is about to happen Category 3: Physical Symptoms

4 Skipping, racing or pounding of the heart (palpitations) Pain, pressure or tightness in the chest Tingling or numbness in the toes or fingers Butterflies or discomfort in the stomach Constipation or diarrhea Restlessness or jumpiness Tight or tense muscles Sweating, not brought on by heat A lump in the throat Trembling or shaking Rubbery or jelly legs Feeling dizzy, light-headed or off balance Choking or smothering sensations, difficulty breathing Headaches or pains in the neck or back Hot flashes or cold chills Feeling tired, weak or easily exhausted Total: BECK DEPRESSION INVENTORY: Instructions: Please circle one number in each group that best describes your feelings I do not feel sad. 1. I feel sad. 2. I am sad all the time and can t snap out of it. 3. I am so sad or unhappy that I can t stand it I am not particularly discouraged about the future. 1. I feel discouraged about the future. 2. I feel I have nothing to look forward to. 3. I feel that the future is hopeless and that things cannot improve I do not feel like a failure. 1. I feel I have failed more than the average person has. 2. As I look back on life, all I can see is a lot of failures. 3. I feel I am a complete failure as a person I get as much satisfaction out of things as I use to. 1. I don t enjoy things the way I use to. 2. I don t get real satisfaction out of everything anymore. 3. I am dissatisfied or bored with everything.

5 5. 0. I don t feel particularly guilty. 1. I feel guilty a good part of the time. 2. I feel quite guilty most of the time. 3. I feel guilty all the time I don t feel I am being punished. 1. I feel I may be punished. 2. I expect to be punished. 3. I feel I am being punished I don t feel disappointed in myself. 1. I am disappointed in myself. 2. I am disgusted with myself. 3. I hate myself I don t feel I am any worse than anybody else. 1. I am critical of myself for my weaknesses or mistakes. 2. I blame myself all the time for my faults. 3. I blame myself for everything bad that happens I don t have any thoughts of killing myself. 1. I have thoughts of killing myself, but I would not carry them out. 2. I would like to kill myself. 3. I would kill myself if I had a chance I don t cry anymore than usual. 1. I cry more now than I use to. 2. I cry all the time now. 3. I use to be able to cry, but now I can t even though I want to I am no more irritated by things than I ever am. 1. I am slightly more irritated now than usual. 2. I am quite annoyed or irritated a good deal of the time. 3. I feel irritated all the time now I have not lost interest in other people. 1. I am less interested in other people than I use to be. 2. I have lost most of my interest in other people. 3. I have lost all my interest in other people I make decisions about as well as I ever could. 1. I put off making decisions more than I use to. 2. I have greater difficulty in making decisions than before. 3. I can t make decisions at all anymore.

6 I don t feel that I look any worse than I used to. 1. I am worried that I am looking old or unattractive. 2. I feel that there are permanent changes in my appearance that make me look unattractive. 3. I believe that I look ugly I can work about as well as before. 1. It takes an extra effort to get started at doing something. 2. I have to push myself very hard to do anything. 3. I can t do any work at all I can t sleep as well as usual. 1. I don t sleep as well as I use to. 2. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3. I wake up several hours earlier than I use to and cannot get back to sleep I don t get more tired than usual. 1. I get tired more easily than I use to. 2. I get tired from doing almost anything. 3. I am too tired to do anything My appetite is not worse than usual. 1. My appetite is not as good as it use to be. 2. My appetite is much worse now. 3. I have no appetite at all anymore I haven t lost much weight, if any, lately. 1. I have lost more than five pounds. 2. I have lost more than ten pounds. 3. I have lost more than fifteen pounds I am no more worried about my health than usual. 1. I am worried about physical problems such as aches and pains, upset stomach, or constipation. 2. I am very worried about physical problems and it s hard to think of much else. 3. I am so worried about my physical problems that I can t think about anything else I have not noticed any recent changes in my interest in sex. 1. I am less interested in sex than I used to be. 2. I am much less interested in sex now. 3. I have lost interest in sex completely. Total:

7 How do you rate your overall quality of sleep? (Please circle one response) 0-Bad (0-2 hours of sleep/night) 1-Fair (2-4 hours of sleep/night) 2-Good (4-6 hours of sleep/night) 3-Great (6-8 hours of sleep/night) EMERGENCY NOTIFICATION: IN CASE OF AN EMERGENCY PLEASE NOTIFY: NAME: PHONE# RELATIONSHIP: IF YOU HAVE ANY QUESTIONS, CALL THE ALLIANCE COMMUNITY HOSPITAL SLEEP CENTER AT (330)