Sleep Disorders Center of Santa Maria
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- Virginia Marshall
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1 SLEEP QUESTIONNAIRE Patient Name: Sex: Date of Birth: Occupation: Usual Work Hours/Days: Referring Physician: Family Physician: Marital status: Single Married Divorced Widowed Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. My Main Sleep Complaint(s) Is: Trouble sleeping at night For how many months/years? Being sleepy all day For how many months/years? Snoring For how many months/years? Unwanted behaviors during sleep, explain Other, explain Sleep Pattern Work Days (Weekday) Off Days (Weekends) Typical bedtime: a.m./p.m. a.m./p.m. Typical amount of time it takes to fall asleep: Typical number of awakenings per night: List any activities that you normally do during nighttime awakening(s), i.e., restroom, eat, watch TV: Typical amount of time to fall back asleep after an awakening: Typical wake up time: a.m./p.m. a.m./p.m. 1
2 Desired wake up time: a.m./p.m. a.m./p.m. How do you usually awaken? i.e., alarm clock: Total amount of sleep per night: Please check all of the following statements that are true about your sleep: Sleep Habits My child usually watch TV or read in bed prior to sleep I often travel across 2 or more time zones I drink alcohol prior to bedtime I smoke prior to bedtime or when I awaken during the night I eat a snack at bedtime I eat if I wake up during the night I typically wake up from sleep to go to the bathroom I have trouble falling asleep I often wake up during the night I am unable to return to sleep easily if I wake up during the night I have thoughts that start racing through my mind when I try to fall asleep I wake up early in the morning, and I am still tired but unable to return to sleep I have nightmares as an adult I experience a creeping-crawling or tingling sensation in my legs when I try to fall asleep I sweat a great deal during sleep I cannot sleep on my back Breathing I have been told that I stop breathing while I sleep I wake up at night choking, smothering or gasping for air I have been told that I snore I have been told that I snore only when sleeping on my back I have been awakened by my own snoring Restlessness I have uncomfortable feelings in my legs and/or arms when I lie down at night I have to move my legs or walk to relieve the uncomfortable feelings in my legs I am a restless sleeper I have been told that I kick or jerk my legs and/or arms during sleep I have a hard time falling asleep because of my leg movements I have talked in my sleep as an adult I have walked in my sleep as an adult I grind my teeth in my sleep 2
3 Daytime Sleepiness I take daytime naps I have a tendency to fall asleep during the day I have had blackouts or periods when I am unable to remember what just happened I have fallen asleep while driving I have had auto accidents as a result of falling asleep while driving I fall asleep while watching TV I fall asleep during conversations I fall asleep in sedentary situations I performed poorly in school because of sleepiness I have had injuries as the result of sleepiness I have had sudden muscle weakness in response to emotions such as laughter, anger, or surprise I have had an inability to move while falling asleep or when waking up I have had hallucinations or dreamlike images or sounds when falling asleep or waking up I drink caffeinated beverages during the day: cups/bottles/cans per day Social History Sleep alone Share a bed with someone Share a bedroom, but have separate beds Share a dwelling, but have separate bedrooms Vital Statistics Medical History What is your: Height? feet inches Weight? pounds Neck Size: What was your weight one year ago? pounds Past Sleep Evaluation and Treatment I have had a previous sleep disorder evaluation I have had a previous overnight sleep study I have had a daytime nap study Five years ago? pounds I have been prescribed a CPAP or bilevel PAP machine for home use I have had surgical treatment for a sleep disorder I have previously been prescribed medication for a sleep disorder I have previously been treated for a sleep disorder Past Medical History Hypertension (high blood pressure) Hepatitis/jaundice Heart Disease Hearing impairment 3
4 Diabetes Depression or severe anxiety Stomach or colon problems Alcoholism Lung problems/copd/asthma Chemical dependency or abuse Reflux Fibromyalgia Female Stroke Premenstrual syndrome TIA "Light Stroke" Menopause Blackouts Seizures Male Back or joint problems (arthritis) Prostate problems Cancer Erectile dysfunction/impotence Thyroid problems Check any of the following symptoms you have had in the past 12 months: Frequent headaches Frequent heartburn / indigestion Fainting or passing out Abdominal pain Sudden loss of vision or strength Frequent constipation Inability to speak Frequent diarrhea Hearing loss or ringing in ear(s) Rectal bleeding / black stools Hoarseness for more than 2-4 weeks Difficulty urinating / incontinence Nosebleeds Blood in urine Cough for more than 2-4 weeks Urinating more than 2 times per night Coughing up blood Pain in joints or bones Shortness of breath or wheezing Unusual bruising or bleeding Swelling in feet or ankles Epilepsy / seizures Chest pain, tightness or pressure Change in wart, mole or skin growth Weight loss of more than 5-10 lbs. Difficulty swallowing or food "sticking" Using the Answer Key below, please circle the number that best applies to your life over the past 6 months. 4
5 Answer Key 1 Never 2- Rarely 3 Sometimes 4 Usually 5 Always I have trouble falling asleep I wake up often during the night At bedtime, thoughts race through my mind At bedtime, I feel sad and depressed When falling asleep, I feel paralyzed (unable to move) When falling asleep, I have restless legs (creepy-crawly feelings, aching, or inability to keep legs still) If I wake up during the night, I have trouble getting back to sleep because of restless legs or leg movements I wake up suddenly gasping for breath, unable to breathe At night my heart pounds, beats rapidly, or beats irregularly I sweat a great deal at night My sleep is disturbed by sadness or depression I have a lot of nightmares (frightening dreams) I feel unable to move (paralyzed) after a nap I have dream-like images (hallucinations) as I wake up in the morning, even though I know I am not asleep I have slept for several days at a time, or at least I have been overwhelmingly sleepy for that long I have been unable to sleep at all for several day I feel that I have insomnia I am very sleepy during the day and I struggle to stay awake In the past 6 months I have fallen asleep while eating, talking to someone, riding in a bus or car, reading a book, watching TV or a movie, or listening to a lecture 5
6 I now have trouble doing my job because of sleepiness or fatigue I often have to let someone else drive the car because I am too sleepy to drive I see dream-like images (hallucinations) either just before or just after a daytime nap, yet I am sure I am awake when they happen I often am unable to move (paralyzed) when I am waking up in the morning Sometimes I realize I have driven my car to the wrong place, and I can t remember how I did it I get "weak knees" when I laugh I get sudden muscular weakness (or even a brief period of paralysis, being unable to move) when laughing, angry, or in situations of strong emotion My desire or interest in sex is less than what it used to be I am unhappy about loving relationships in my life I have considered or attempted suicide Someone in my family has been hospitalized for a psychiatric illness or "nervous breakdown" I smoke tobacco within two hours before bedtime I have problems with my nose blocking up when I am trying to sleep (allergies, infections) My snoring or my breathing problem is much worse if I sleep on my back My snoring or my breathing problem is much worse if I fall asleep right after drinking alcohol
7 BED PARTNER QUESTIONNAIRE Name of Patient: Date: Check any of the following behaviors that you have observed the patient doing while asleep: Loud snoring Light snoring Twitching of legs or feet Pauses in breathing Grinding teeth Sleep talking Sleepwalking Bedwetting Sitting up in bed while still asleep Head rocking or banging Kicking with legs Getting out of bed while still asleep Biting tongue Becoming very rigid and/or shaking How long have you been aware of the sleep behavior(s) that you checked above? Describe the behavior(s) checked above in more detail. Include a description of the activity, the time during the night when it occurs, how many times during the night and whether it occurs every night. If you have heard loud snoring, describe it in more detail. Include descriptions of any pauses in breathing or occasional loud snorts that you may have noticed. 7
8 EPWORTH SLEEPINESS SCALE 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. 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 SITUATION 1.) Sitting and reading ) Watching TV ) Sitting inactive in a public place (ie: a theatre or meeting) ) As a passenger in a car for an hour without a break ) Lying down to rest in the afternoon when circumstances permit 6.) Sitting and talking to someone ) Sitting quietly after lunch without alcohol ) In a car, while stopped for a few minutes in traffic TOTAL
Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. For how many months/years?
St. Louis Heart and Vascular - McKelvey Office May 28, 2018 (Page 1) Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. Today s Date: My Main
SLEEP QUESTIONNAIRE. Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone:
SLEEP QUESTIONNAIRE Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone: Please fill in the blanks, and check appropriate areas on the
ST CHARLES HOSPTIAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE. Patient Name: Date of Birth: SS# Address: Male Female
ST CHARLES HOSPTIAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE Patient Name: Date of Birth: SS# Address: Male Female Email address Home Telephone #: ( ) Cell Phone: # ( ) HOW DID YOU HEAR ABOUT US? Referred
Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
LIBERTY SLEEP ASSOCIATES, LLC SLEEP DISORDERS CENTER
SLEEP QUESTIONNAIRE Patient Name: Sex: Age: Date: Occupation: Usual Work Hours/Days: Family Physician (PCP): Ht Wt Neck Size: What was your weight one year ago? Five years ago? Marital status: (circle
PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
Associated Neurological Specialties and Sleep Disorder Center
Sleep Center Questionnaire Name: Sex: Age: Date: Date of Birth: Height: Weight: Neck Size: Primary Care Physician: Referring Physician: Main Sleep Issues/Complaints Trouble falling asleep Trouble staying
Sleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?
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Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
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Dr. Michael Baten is The Santa Fe SleepDoctor NEUROLOGY / ADULT AND PEDIATRIC SLEEP MEDICINE
Dear Patient, Please complete the enclosed paperwork in which you provide information regarding your sleep problem, and bring it with you to your appointment with Dr. Baten scheduled for: Date: _ Time:
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
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*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
SLEEP HISTORY QUESTIONNAIRE
Date of birth: Today s date: Dear Patient: SLEEP HISTORY QUESTIONNAIRE Thank you for taking the time to fill out a sleep history questionnaire. This will help our healthcare team to provide the best possible
Sleep Questionnaire. Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago:
Sleep Questionnaire Patient's Name: Referring Dr.: Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago: Weight 5 years ago: 5 yrs ago: 10
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
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Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
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New Patient Sleep Intake
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Patient History & Sleep Questionnaire
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PATIENT SLEEP QUESTIONNAIRE
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Maintenance for Wakefulness Testing (MWT)
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PATIENT DEMOGRAPHICS
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Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D.
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Sleep Disorders Questionnaire
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Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
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EMORY SLEEP CENTER Sleep and Health Questionnaire
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Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
General Questionnaire
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PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
SLEEP QUESTIONNAIRE. Please briefly describe your sleep or sleep problem:
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Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
![Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy](/thumbs/96/127246551.jpg "Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy")
Health Benefits Employee Services HBE Preventive Health - Sleep Assessment Form Please bring your completed assessment form to your appointment. To schedule an appointment please call 505 844-HBES (4237).
I would like for my patient to be seen in Sleep Medicine consultation and managed by the sleep physician. Yes No
701 E. COUNTY LINE ROAD, SUITE 207. GREENWOOD, IN. 46143 OFFICE317-887-6400 FAX 317-887-6500 indianasleepcenter.com REFERRAL FOR SLEEP EVALUATION Patient Name:_ Phone: I would like for my patient to be
Tallahassee Memorial Sleep Center Patient Questionnaire
Tallahassee Memorial Sleep Center Patient Questionnaire Name _ Age Date Date of Birth Sex Height ft in Weight lbs Neck size inches (If known) Body Mass Index (BMI) (If known) Phone(s) (home) (work) (cell)
BMI: Family physician : Neck circumference (cm) Hypertension + 4 cm Snoring + 3 cm Witnessed apnea + 3cm Total
Last and first names: F M Date: Date of birth: / / YYYY MM DD Weight: kg /lbs Profession/job: Height: _ cm /ft.in. BMI:_ Family physician : ANC (adjusted neck circumference) : Neck circumference (cm) Hypertension
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like t like
Iowa Sleep Disturbances Inventory (ISDI)
Department of Psychological & Brain Sciences Publications 1-1-2010 Iowa Sleep Disturbances Inventory (ISDI) Erin Koffel University of Iowa Copyright 2010 Erin Koffel Comments For more information on the
Southwestern Neuroscience Institute Neurology Seizure and Sleep Clinic M: F:
Patient Pre-Study Instructions Please read the following information below to assist us in making your overnight study more comfortable, as well as maximizing the quality of our data collection. Before
Section of Pediatric Sleep Medicine
Section of Pediatric Sleep Medicine David Gozal, MD Hari Bandla, MD Date: Dear Parent or Caregiver; Thank you for your interest in the Sleep Disorders Program. The sleep clinic s standard assessment procedure
GARY POLK, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT
GARY POLK, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Pharmacy/Location Date: Age: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3) YOUR PAST MEDICAL HISTORY
SLEEP STUDY. Nighttime. 1. How many hours of sleep are you now getting in a typical night?
SLEEP STUDY Patient Name: Date of Birth: Date of Study: This questionnaire involves a broad range of sleep and sleep-related behaviors. Your answers enable us to develop a clearer picture of your sleep/wake
Rex Surgical Specialist (Bariatric Office)
Rex Surgical Specialist (Bariatric Office) Medical History Information Today s Date Name DOB Referring Physician phone_ Primary Care Physician phone_ Office Office Medical History (Please Mark all that
1. a. Please state in your own words why you (or your physician) asked for a sleep evaluation.
Jupiter Medical Center Sleep Center 1230 S. Old Dixie Highway Jupiter, FL 33458 (561) 744-4478 Fax (561) 748-4114 Email: Sleep@jupitermed.com S L E E P C E N T E R An ACHC Accredited Sleep Facility Sleep
Robert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study
NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A 811 West Interstate 20, Suite G12 Arlington, Texas 76017 (817) 419-6375 Fax (817) 419-6371 Robert E. McMichael, M.D. Medical Director
Humble Dreams Sleep Center. Humble, TX 77339
Humble Dreams Sleep Center 8901 FM 1960 Bypass West, Ste. 306 Humble, TX 77339 Dear Humble Dreams Sleep Study Patient, Thank you for allowing Humble Dreams Sleep Center to provide your sleep study as requested
PEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
Adult Sleep Questionnaire. Name: (First) (middle) (Last) Address: (Street) (City) (State) (Zip) Marital Status: Spouse s Name:
Adult Sleep Questionnaire Date: / / Name: (First) (middle) (Last) Address: _ (Street) (City) (State) (Zip) Date of birth: / / Age: Home Phone: ( ) - Work Phone: ( ) - Height: Weight: Neck Size: Marital
Room # Critical Care & Pulmonary Consultants, P.C.
Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate
Patient Questionnaire
Patient Questionnaire Name: Date of Birth: Today s Date: What is your main sleep complaint and how long has it occurred? Have you ever had a sleep study before? If yes, please tell us when and where it
PEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
Your Sleep Study will begin the night of at 8 p.m. and will end the following day between 6 a.m. and 7 a.m.
SLEEP DISORDERS CENTER St. Joseph Mercy Ann Arbor 5305 Elliott Drive, Ypsilanti, MI 48197 734-712-2276 / Fax 734-712-2967 Sleep Study Information Dear _, Your Sleep Study will begin the night of at 8 p.m.
Original Sleep Hygiene Rules*
Original Sleep Hygiene Rules* 1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing time in bed a bit seems to solidify sleep; excessively long times
Patient Adult Information History
Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how
EPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
The Medical Center Sleep Center
The Medical Center Sleep Center Date: / / Name: Age: (First) (M.I.) (Last) Address: (Street / P.O. Box) (City) (State) (Zip) (County) Phone: Home ( ) Work ( ) Date of Birth: / / Education: Marital Status: