*521634* Sleep History Questionnaire. Name of primary care doctor:

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1 *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. This information is important for your sleep provider to help you with your sleep problems. If there is someone else who sleeps with you or near you, they can help you answer some of these questions. Name: Address: Insurance: Name of insured: Name of primary care doctor: Address: Date of birth: Home phone: Work phone: Cell phone: Policy number: Phone: Please describe the main reason for your sleep appointment? How long has this been a problem? Have you been diagnosed with a sleep problem in the past? YES NO If so, what? When? What treatment was recommended? Have you had a sleep study done in the past? YES NO If yes, where? When? Sleep habits: Do you read in bed? Do you watch TV in bed? YES NO Do you eat in bed? Do you do work in bed? YES NO Do you use a phone or computer in bed? YES NO /14/16 Original: Medical Record Page 1 of 7

2 Is your sleep disturbed by (check all that apply): Bed partner: Children: Noise: Pets: Other: On two or more nights per week, do you drink alcohol to help you fall asleep? On two or more nights per week, do you take melatonin to help you fall asleep? On two or more nights per week, do you take over-the-counter medicine to fall asleep? Do you take drinks with caffeine (coffee, tea, soda pop, energy drinks)? Do you have 3 or more caffeine drinks in a day? Do you have caffeine drinks within 6 hours of bedtime? Do you smoke or use tobacco? Do you exercise? How often? Sleep routines: What time do you usually get into bed on workdays? AM/PM Days off work? AM/PM What time do you get out of bed on workdays? AM/PM Days off work? AM/PM Do you work the evening or night shift or do your shifts rotate? YES NO How long does it usually take to fall to sleep? How many times do you wake up during the night? minutes / hours How much time do you feel that you are awake during the entire night? minutes / hours How long does it take for you to fall back to sleep after you wake up? minutes / hours Why do you think you wake up? What do you do when you wake up? How much sleep do you think you get on work nights? hours How much sleep do you think you need to feel your best? hours Days off work? hours How many days during a week do you take a nap? For how long? Do you feel better after taking a nap YES NO If you could choose the best sleep schedule for you, what time would you go to bed? AM/PM What time would you get up? AM/PM /14/16 Original: Medical Record Page 2 of 7

3 Sleep symptoms: Leg movements Do you ever have restless, crawling, aching or other unusual feelings in your legs? Do you ever wake yourself by kicking your legs during the night? Are the sheets and blankets messed up or tossed about when you get up? Night-time behaviors Do you have nightmares or night terrors? How often? Have you had times when you were sleep walking? Have you been seen doing anything unusual while you sleep at night? What? How often? Have you ever hurt yourself or someone else while you were asleep? Please describe: Do you clench or grind your teeth during the night? Sleep apnea (pauses in breathing during sleep) Do you wake with a headache in the morning? How often? Does your bed partner, family or friends ever say that you snore? If so, how did they describe your snoring? Mild Moderate Loud Frequent Rare Do you ever wake yourself up from snoring, gasping or choking? Do you ever have to sleep in a separate room because of your snoring? Have you ever been told that you stop breathing or have pauses in your breathing? Do you wake in the morning with a dry throat or mouth? Do you have trouble breathing through your nose? Do you have problems with heartburn, reflux or a hiatal hernia? Which position(s) do you usually sleep in? (circle all that apply) Stomach Back Sides All Do you use oxygen or any other medical equipment when you sleep? Do other members of your family (related by blood) snore? Have any members of your family been diagnosed with sleep apnea? YES NO Don t know YES NO Don t know /14/16 Original: Medical Record Page 3 of 7

4 Do other members of your family (related by blood) have sleep problems? If so, what type of problem? Have you ever had an accident, or near accident due to sleepiness while driving? Does your sleepiness affect your work on the job or at school? Do you ever fall asleep by accident while doing a task? Narcolepsy (sudden daytime sleeping) Have you had sudden muscle weakness when you are laughing, angry or surprised? Have you ever been unable to move your body when falling asleep or waking up? Do you ever have trouble separating your dreams from real life events? Please describe: In general, is your health: Excellent Good Fair Poor Physical health (includes illness and injury): During the past 30 days, on how many days was your physical health not good? Mental health (includes stress, depression, and problems with emotions): During the past 30 days, on how many days was your mental health not good? During the past 30 days, on how many days did poor physical or mental health keep you from doing your usual activities? This might be self-care, work or play? of 30 days of 30 days of 30 days Social history Marital status: single married divorced widowed Who lives in your home with you? Mother: Alive Dead If has died, from what? Father: Alive Dead If has died, from what? Siblings? Yes No Have any died? Yes No If so, from what? Currently working? Yes No If yes, work: Former jobs: /14/16 Original: Medical Record Page 4 of 7

5 Surgery history List the surgeries that you have had in the past. Surgery date (estimate) Medical conditions List all current and past medical conditions. Date you were diagnosed How often Medicines List all your current medicines, both prescription and over-the-counter. Dose How often /14/16 Original: Medical Record Page 5 of 7

6 Sleepiness scale: The following questions ask how likely you are to fall asleep or doze off, when you should be awake. Do not include times when you are just feeling tired. Think about how you ve felt in recent days. If you have not done some of these things recently, try to recall what happened. Use the following numbers to show your answer: 0 = No chance of dozing 2 = Moderate chance of dozing 1 = Slight chance of dozing 3 = High chance of dozing Situation Sitting and reading Chance of dozing Watching TV Sitting in a public place (for example, at a theater or in a meeting) Riding in a car for an hour without a break (as a passenger) Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, stopping for a few minutes in traffic /14/16 Original: Medical Record Page 6 of 7

7 Are you currently having any of the following symptoms? Please check Yes or No for each problem. YES NO General YES NO Lungs Obvious weight gain or loss Shortness of breath at rest Fever, chills or sweats Shortness of breath with activity Drug allergies Dry cough List drug: Coughing up mucus or phlegm Coughing up blood YES NO Eyes Wheezing when breathing Changes in vision YES NO Lymph system Blind spots Swollen lymph nodes Double vision New lumps or bumps Other: Changes in breasts or discharge YES NO Digestive system YES NO Ear, Nose and Throat Nausea or vomiting Ear pain Loose or watery stools (diarrhea) Sore throat Hard, dry stools (constipation) Sinus pain Fat or grease in stools Post-nasal drip Blood in stools Runny nose Stools are black or bloody Bloody nose Abdominal (belly) pain Other: YES NO Urinary tract YES NO Heart Pain when you urinate (pee) Rapid or irregular heart beats Blood in your urine Chest pain or pressure Urinate (pee) more than normal Out of breath when lying down Irregular periods Swelling in feet or legs High blood pressure YES NO Muscles and bones Heart disease Muscle pain Joint or bone pain YES NO Nervous system Swollen joints Headaches Other: Weakness in arms or legs YES NO Glands Numbness in arms or legs Increased thirst or urination Other: Diabetes: Morning glucose YES NO Skin Afternoon glucose Rashes YES NO Mental health New moles or skin changes Depression Other: Anxiety Other mental health issues Patient signature Date Time /14/16 Original: Medical Record Page 7 of 7

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