PATIENT SLEEP QUESTIONNAIRE
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1 PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb What is your primary concern/ problem regarding your sleep? Not including your primary care physician, have you seen another physician for your sleep problem? Yes No If yes, who was the physician? _ When were you seen? Did you have a sleep study? Yes No If yes, Date Where What treatment, if any, was recommended? SLEEP HYGIENE What time do you usually go to bed? AM/PM What time do you usually get up? _AM/PM Do you take naps during the day? Yes No If yes, how many naps daily? for how long? Do you have difficulty falling asleep? Yes No If yes, how long does it take to fall asleep? minutes/ hours Do you wake up during the night? Yes No If yes, number of occurrences per night _for how long? Page 1 of 7
2 SLEEP DISTURBANCES Do you snore? Indicate the severity of your snoring using the following scale: Mild: Heard in the room Moderate: Heard outside the open bedroom door. Severe: Heard outside the closed bedroom door. Awaken from sleep feeling short of breath, gasping or choking Have you be told you stop breathing while asleep Have headaches upon waking Awaken confused or disoriented Feel sleepy or tired during the day Awaken feeling unrested or unrefreshed Experiencing a decrease in memory or ability to concentrate due to sleepiness Experience sudden weakness, buckling of knees, or facial heaviness when laughing, angry, scared, or crying Feel totally unable to move (paralyzed feeling) upon awakening or falling asleep Experience vivid dreamlike scenes, smells or sounds upon awakening or falling asleep. (Similar to hallucinations) Find yourself doing complex tasks of which you were totally unaware (such as driving/ navigating without conscious awareness) Have nightmares or night terrors Act out your dreams Sleepwalk Other unusual behavior? Please explain Feel restlessness, agitation or discomfort in your legs before or at bedtime Does this disturb your sleep? How often do you experience this? Nightly Infrequently Weekly Yes No For Physician Page 2 of 7
3 EPWORTH SLEEPNESS SCALE How likely are you to doze off or fall asleep in the following situation? Rate each description in according to your normal way of life in recent times. Even if you have not been in some of these situations recently, try to determine how sleepy you would have been. Use the following Scale to choose the best number for each situation. SITUATION Sitting and Reading Watching Television Sitting inactive in a public place (e.g., a theater or meeting Lying down to rest in the afternoon when circumstances permits Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic As a passenger in a car for an hour without a break CHANCE OF DOZING Scale 0= Would never doze 1= Slight chance of dozing 2= Moderate chance of dozing 3= High chance of dozing Total: MEDICAL HISTORY Medical History: Have you now or in the past experienced any health problems in the following areas? High blood pressure COPD Asthma Thyroid Disease Sinus problems Diabetes Heart Disease Heartburn / Reflux Psychiatric (depression, anxiety) Chronic pain Stroke / TIA Fibromyalgia Please list any other medical problems you have or have had: Page 3 of 7
4 Family History: Please provide any medical problems and sleep issues that have been diagnosed in your family. Mother Father Siblings Children Allergies: Please list any medication allergies or drug reactions you have or have had. Medications: Please list any medication you are currently taking with the dose and how often they are taken. Include over-the-counter sleeping pills such as Melatonin and include as well any herbal remedies and vitamins/supplements. If you have provided a list you may skip this question Name Dosage Frequency Page 4 of 7
5 Past Surgical History: Please list any surgical procedures and the approximate date of the procedure Procedure Date SOCIAL HISTORY Occupation: Do you drink alcohol? Never Occasionally Frequently Alcoholic Do you smoke tobacco? Yes No How much per day? How many years? When did you quit? (Year) Do you use recreational drugs? Yes No, Type Do you currently drink caffeinated beverages? Yes No; Amount Weight change in the past 12 months: Yes No; Amount lost/ gained (circle): Weight change in the past 5 years: Yes No; Amount lost/ gained: REVIEW OF SYSTEMS Constitutional ENT/ Allergy Good general health Yes No Trouble breathing (nose) Yes No Fatigue Yes No Night time congestion Yes No Weight gain Yes No Hoarse voice Yes No Weight loss Yes No Trouble swallowing Yes No Other: Other: Heart Lungs Chest pain Yes No Chronic cough Yes No Leg swelling Yes No Pain w/ breathing Yes No Palpitations/ Irregular heartbeat Yes No Shortness of breath with mild exertion Yes No Other: Shortness of breath when lying flat Yes No Page 5 of 7
6 Skin Musculoskeletal Rash Yes No Joint pain or swelling Yes No Itching Yes No Chronic back pain Yes No Dry Skin Yes No Muscle pain or Weakness Yes No Other: Other: Endocrine/ Other Gastrointestinal Poor appetite Yes No Heat Intolerance Yes No Frequent Indigestion Yes No Cold Intolerance Yes No Frequent nausea/ vomiting Yes No Sexual Dysfunction Yes No Frequent Diarrhea Yes No Hot flashes Yes No Freq. Constipation Yes No Other Bloating Yes No Abdominal Pain Yes No Diverticulitis Yes No Other Genital/ Urinary Neurological Blood in urine Yes No Dizziness Yes No Lack of sex drive Yes No Loss of strength Yes No Freq. (Night) urination Yes No Frequent headaches Yes No Urinary incontinence Yes No Imbalance Yes No Males: Loss of feeling Yes No Trouble w/ erections Yes No Trouble walking Yes No Females: Numbness/ tingling Yes No Irregular periods Yes No Other Postmenopausal Yes No Other Psychiatric Nightmares Yes No Feel depressed Yes No Feel nervous or tense Yes No Suicidal thoughts Yes No Mood swings Yes No Difficulty concentrating Yes No OCD ADD ADHD Yes No Other Patient signature: Date: Page 6 of 7
7 PATIENT DEMOGRAPHICS Patient Name: Address: Date of Birth: _ Social Security #: Telephone # s: Home _ Cell #:_ Work #: Employer:_ Primary Medical Insurance: Telephone #: Name of Insurance Subscriber:_ Relationship to Patient: Subscriber s Address: Subscriber s Social Security Number: Subscriber s Date of Birth: Policy ID #:_ Group # _ Secondary Medical Insurance: Telephone #: Name of Insurance Subscriber:_ Relationship to Patient: Subscriber s Address: Subscriber s Social Security Number: Subscriber s Date of Birth: Policy ID#: Group# Emergency Contact Person: Name: Relationship: _ Primay Telephone # Secondary Telephone #: ** Due to HIPAA Privacy regulation, may we contact you at the above telephone numbers provided; to discuss anything pertaining to your evaluation, sleep study, etc. at Hunterdon Medical Center. Preferred Method of Contact: Signature of patient/ guardian Date Legal Guardian or Closest Relative Relationship Page 7 of 7
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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
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Pulmonary Associates of LVPG A practice of Lehigh Valley Physician Group 1250 S. Cedar Crest Blvd., Suite 205, Allentown, PA 18103 1770 Bathgate Drive, Suite 403, Bethlehem, PA 18017 610-439-8856 (phone)
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