SLEEP-WAKE QUESTIONNAIRE
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1 Shasta Critical Care Specialists Sleep Center: (530) , 2701 Old Eureka Way, Suite 1J, Redding, CA Office: (530) , 2701 Old Eureka Way, Suite 1E, Redding, CA Fax: (530) SLEEP-WAKE QUESTIONNAIRE This questinnaire is fr patients 18 years f age r lder that have a scheduled appintment at the Sleep Center. It will take apprximately 20 t 30 minutes t cmplete. The infrmatin yu prvide is very imprtant and will assist the sleep specialist during the review f yur sleep symptms. Please respnd t all questins by checking the apprpriate bx, encircling the prvided respnses, r cmpleting the free text sectins. Name: Tday s Date: _ DOB: Age: Sex: Scheduled Appintment Date: Height (inches): Weight 1 year ag: Marital Status: Sleep Specialist: Weight nw (lbs): Weight 5 years ag: Number f Children: I was referred by: Name f Dctr: Other: Specific issues I want t discuss at my appintment (please, list in rder f cncern):
2 1. SLEEP SCHEDULE What time d yu g t bed n weekdays? What time d yu g t bed n weekends? What time d yu get ut f bed n weekdays? What time d yu get ut f bed n weekends? a.m. p.m. a.m. p.m. a.m. p.m. a.m. p.m. Hw much sleep d yu get n an average night (hurs)? Are yu... A mrning Type, An evening Type, Neither evening r mrning type What wuld be yur ideal bedtimes? (frm (a.m./p.m.) t (a.m./p.m.)) D yu nap? N Yes Hw ften d yu nap? (number f times per week) Hw lng are the naps? (in minutes) D yu awaken refreshed frm the nap? N Yes What are yur usual wrk hurs? Are yu a shift wrker? N Yes If yes, what kind f shift d yu wrk (hurs)? What is (was) yur ccupatin? If retired, when? 2. SLEEP HISTORY D yu have difficulty falling asleep? N Yes D yu have difficulty staying asleep? N Yes D yu wake up t early and cannt get back t sleep? N Yes D yu have thughts racing thrugh yur mind that make it difficult t sleep? N Yes Hw lng des it take yu t fall asleep at night (minutes)? D yu read in bed? N Yes D yu watch TV in bed? N Yes 2
3 D yu share the bed with anyne? N Yes Des yur partner have a sleep disrder? N Yes D yu have pets sleep in the bedrm? N Yes Is yur bedrm cmfrtable? N Yes If n, please describe Hw many times d yu wake up during the night? Hw lng des it take yu t fall asleep again (minutes)? D yu have unpleasant feelings f fear, anxiety, tensin, r unhappiness waking yu up? N Yes D yu have feelings f muscle tensin r tightness in yur arms r chest? N Yes D yu have pain r jint discmfrt? N Yes D yu have ther prblems waking yu up? N Yes If yes, please describe: In the mrning, d yu wake up: Wake up naturally, With an alarm, Bth In the mrning, d yu wake up feeling: Refreshed, Sleepy/Grggy, Tired 3. ABNORMAL MOVEMENTS/BEHAVIORS D yu have r have yu ever experienced: An urge t mve yur legs, usually accmpanied by uncmfrtable and unpleasant sensatins in the legs? N Yes Discmfrt in the legs that wrsen during perids f rest r inactivity such as laying dwn r sitting? N Yes Discmfrt in the legs that is relieved by mvement: walking r stretching? N Yes Discmfrt that wrsens during the nighttime? N Yes D yu have leg cramps (Charley hrse)? N Yes D yu kick, punch, r pke yur bed partner while asleep? N Yes If yes, have yu ever injured yur bed partner r yurself? N Yes D yu grind yur teeth? N Yes 3
4 D yu wear a bite splint (muth guard)? N Yes D yu walk in yur sleep? N Yes If yes, when was the last time? D yu talk in yur sleep? N Yes D yu have nightmares r night terrrs? N Yes If yes, please describe the behavir, including the time f night and hw frequently? Have yu acted ut yur dreams? N Yes D yu make rlling mvements r bang and twist yur head at night? N Yes Have yu had sleep prblems as a child? N Yes If yes, please describe 4. DAYTIME SLEEPINESS Have yu fallen asleep unexpectedly? N Yes Have yu ever had an accident r near-miss because yu have fallen asleep while driving? N Yes If yes, when? D yu kick r jerk yur arms r legs during sleep? N Yes Are yur bed cvers messy in the mrning? N Yes Have yu ever experienced sudden muscle weakness when yu laugh, listen t a jke, are surprised r angry? N Yes If yes, during yur episde f muscle weakness. If n, please skip t the next questin. a) Can yu hear? N Yes b) Des yur speech ever becme slurred? N Yes c) c) Is yur head affected? N Yes d) d) Is yur whle bdy affected? N Yes e) e) Hw lng des the weakness usually last? Have yu experienced dreamlike images r sunds while falling asleep r waking up? N Yes 4
5 Have yu experienced an inability t mve while falling asleep r waking up? N Yes 5. SNORING/BREATHING HISTORY D yu snre? N Yes What is yur preferred sleep psitin (% f the time in each)? Back (% f sleep time) Left Side (% f sleep time) Right Side (% f sleep time) Stmach (% f sleep time) Des yur sleep psitin affect yur snring? N Yes D yu awaken chking r shrt f breath? N Yes D yu awaken with a snrt r gasping fr air? N Yes Has anyne nticed yu stp breathing while asleep? N Yes D yu awaken ften t urinate during the night? N Yes D yu awaken with acid r sur taste in yur muth? N Yes D yu have difficulty breathing while n yur back? N Yes D yu avid sharing a rm because f snring? N Yes D yu sweat excessively during the night? N Yes D yu awaken with a dry muth r sre thrat? N Yes 5
6 6. MEDICAL/SURGICAL HISTORY Have yu ever had a sleep study in the past? N Yes If yes, when? If yes, where? D yu use CPAP r BiPAP at hme? N Yes If yes, what pressure setting? D yu use xygen at hme? N Yes If yes, what Liter/flw setting? Have yu ever had tnsils r adenids remved? N Yes Have yu ever had sinus r nasal surgery? N Yes Have yu ever brken yur nse? N Yes Have yu ever had any type f head injury? N Yes Have yu ever had surgery t prmte weight lss? N Yes If yes, when? Have yu had dental surgery r rthdntics? N Yes If yes, Please describe: Please check the apprpriate bx if yu have a histry f any f the fllwing: Hypertensin Cngestive Heart Failure Heart attack Cardiac arrhythmias Strke/TIA Thyrid disease Lung Prblems /COPD/Asthma Pulmnary Hypertensin Diabetes Parkinsn's Anemia/Irn deficiency Heartburn/Reflux Arthritis Sexual dysfunctin/lss f libid Fibrmyalgia Depressin/Anexiety Seizures Menpause Frequent bld dnatins Cnnective tissue disease (e.g. Lupus) Cancer Nasal allergies /cngestin End stage kidney disease/dialysis Other If ther, please specify 6
7 7. FAMILY HISTORY Des any member f yur family have any f the fllwing? Snring r Sleep apnea? N Yes If yes, Relatinship Narclepsy? N Yes If yes, Relatinship Seizure disrder? N Yes If yes, Relatinship Depressin? N Yes If yes, Relatinship Hypertensin, heart disease, heart failure? N Yes If yes, Relatinship Strke? N Yes If yes, Relatinship Diabetes? N Yes If yes, Relatinship 8. ALLERGIES Please list any knwn medicatin r envirnmental (pets, pllens, fd, etc.) allergies Allergies: 7
8 9. MEDICATIONS List current medicatins (give medicatin name, dse, and number f time taken per day), including OTC and vitamin/herbal supplements. Medicatin Name Dse Number f time taken per day 10. SOCIAL HISTORY D yu use tbacc prducts (cigarettes, cigars, chewing tbacc, snuff, pipe)? N Yes If yes Packs per day? If yes, when did yu start? If yes - quit, when did yu quit? D yu drink alchl? N Yes If yes, hw many drinks? per Day Week Mnth D yu drink caffeinated beverages? N Yes If yes, hw many cups (8 z.) per day? _ D yu use recreatinal drugs? N Yes D yu exercise? N Yes 8
9 11. BED PARTNER, PARENT OBSERVATION QUESTIONNAIRE D yu live with the patient? N Yes D yu sleep in the same rm as the patient? N Yes If n, is it because f his/her sleep behavirs (i.e. snres t lud acts ut dreams, etc)? N Yes Check any f the fllwing behavirs that yu have bserved the patient ding while asleep. Lud snring Light snring Pauses in breathing Grinding teeth Twitching f legs r feet during sleep Sleep-talking Sleepwalking Head rcking r banging Bedwetting Sitting up in bed but nt awake Kicking with legs during sleep Biting tngue Getting ut f bed but nt awake Becming very rigid and/r shaking Hw lng have yu been aware if the sleep behavir(s) _ Describe the behavir(s) checked abve in mre detail. Include a descriptin f the activity, the time during the night when it ccurs, frequency during the night and whether it ccurs every night. Name f persn cmpleting this frm: Relatinship t patient: 9
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PATIENT INFORMATION Dear Patient: Sleep prblems are extremely cmmn. Public health and safety are threatened by the increasing prevalence f bstructive sleep apnea, which nw afflicts at least 25 millin adults
For our protection, we require verification that you have received this notice. Therefore, please sign below.
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