Sleep Screening Questionnaire
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- Theresa Chandler
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1 Version: SLPQV1 Sleep Screening Questionnaire OFFICE USE Patient ID: NAME: CURRENT DATE: / / DATE OF BIRTH: / / MALE FEMALE Referring Physician: Contact ID: Number Number #1 = the most severe symptom #1 = the most severe symptom CPAP intolerance Gasping causing waking up Difficulty concentrating Excessive daytime sleepiness Fatigue Forgetfulness Insomnia Nighttime choking spells Sring which affects the sleep of others Witnessed cessation of breathing Frequent sring Other: Write In
2 SLEEP STUDIES If you have had a Sleep Study, please check one of the following: Home Sleep Study Polysomgraphic evaluation at a sleep disorder center Sleep Center Name: Sleep Study / / FOR OFFICE USE ONLY The evaluation confirmed a diagsis of The evaluation showed: during REM Supine Side an RDI of an AHI of a nadir SpO 2 of T90 ODI (Oxygen Desaturation Index) Slow Wave Sleep Decreased None REM Sleep Decreased None Additional Questions Yes No Are you a current CPAP (Continuous Positive Air Pressure) user? If Yes, what are the current CPAP settings: CPAP Intolerance (Continuous Positive Airway Pressure device) If you have attempted treatment with a CPAP device, but could t tolerate it please fill in this section: Refuses CPAP Noise disturbing sleep and/or bed partner's sleep Claustrophobic associations Mask leaks Inability to get the mask to fit properly Other Discomfort from headgear CPAP restricted movements during sleep CPAP does t seem to be effective Pressure on the upper lip causing tooth related problems An unconscious need to remove the CPAP Does t resolve symptoms Noisy Disturbed or interrupted sleep Latex allergy Cumbersome include: Dieting Weight loss Other Therapy Attempts Surgery (Uvuloplasty) Surgery (Uvulectomy)
3 include: Pillar procedure Smoking cessation CPAP BiPAP Other Therapy Attempts Uvulectomy (but continues to have symptoms) Uvuloplasty (but continues to have symptoms) Positional therapy (side sleeping) Nasal strips Epworth Sleep Questionnaire How likely are you to doze off or fall asleep in the following situations? No Slight Moderate High chance of dozing chance of dozing chance of dozing chance of dozing Sitting and reading Watching TV Sitting inactive in 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 afteron when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol I felt fatigued and had less motivation I felt fatigued and did t desire to exercise In a car, while stopped for a few minutes in traffic Fatigue Scale During the past week: No < > Yes I felt fatigued often I felt fatigue that interfered with my physical functioning I felt fatigued which caused me frequent problems I felt fatigued which prevented sustained physical functioning I felt fatigued and couldn't carry out certain duties and responsibilities Fatigue was among my three most disabling symptoms Fatigue interfered with my work, family or social life Total Score:
4 Berlin Questionnaire Sleep Evaluation 1. Complete the following: Height: ft, in Weight: lbs Age: 2. Do you sre? don't kw If you sre: (Answer questions 3-6) 3. Your sring is? slightly louder than breathing as loud as talking louder than talking very loud. Can be heard in adjacent rooms 4. How often do you sre? 5. Has your sring ever bothered other people? 6. Has anyone ticed that you quit breathing during your sleep? 7. How often do you feel tired or fatigued after you sleep? 8. During your waketime, do you feel tired, fatigued or t up to par? 9. Have you ever dded off or fallen asleep while driving a vehicle? If, how often does it occur? 10. Do you have high blood pressure? don't kw
5 Berlin Questionnaire Sleep Evaluation Scoring Questions: Any answer within a box is a positive response Scoring Categories Category 1 is positive with 2 or more positive responses to questions 2-6 Category 2 is positive with 2 or more positive responses to questions 7-9 (BMI = Body Mass Index) Category 3 is positive with a positive response to question 10 and/or a BMI > 30 Final Result: 2 or more possible categories indicates a high likelihood of sleep disordered breathing. Patient Signature I authorize the release of a full report of examination findings, diagsis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. I certify that the medical history information is complete and accurate.
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Psychological Sleep Services Sleep Assessment Name Date **************************************************** Insomnia Severity Index For each question, please CIRCLE the number that best describes your
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
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