General Questionnaire
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- Conrad Harper
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1 General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In your own words, what is the reason you (or your doctor) contacted the Sleep Center? 2. How long have you had this problem? 3. Has anyone in your family had any type of sleep disorder? 4. What time do you usually try to fall asleep? 5. What time do you usually try to get out of bed? 6. Do these times vary? If yes, please explain: 7. How much time do you sleep at night? 8. How many times do you usually awaken each night? Do you have difficulty returning to sleep? 9. How long are you awake altogether during the night?
2 10. How often do you: (when you are trying to fall asleep) never sometimes occasionally often have difficulty falling asleep? have thoughts racing through your mind? feel sad or depressed? have anxiety? worry about not being able to sleep? worry you won t return to sleep after awakening? (just prior to or during sleep) have creeping, crawling or aching feeling in your legs? kick or twitch your legs? have unusual movements while asleep? wake up frequently? have trouble waking up in the a.m.? have restless or disturbed sleep? feel muscular tension? have any kind of pain or discomfort? wake up with chest pain? feel alert and energetic all day? snore loudly? wake up gasping for breath? sweat a lot during the night? wake up with a headache? wake up with a dry mouth? wake up sick to your stomach? walk in your sleep? fall out of bed while asleep? wake up screaming, violent or confused? wet the bed? grind your teeth while sleeping?
3 11. Have you ever had vivid dream-like scenes just as you are falling asleep? If yes, briefly explain: 12. Have you every felt paralyzed (could not move) just as you were falling asleep or waking up? If yes, please explain: 13. How many naps do you take in a usual week? length of naps? Are they refreshing? 14. Do you have episodes of sudden muscular weakness when laughing, angry or in an emotional situation? If yes, please explain: 15. Have you had your tonsils or adenoids removed? 16. Can you breathe easily through your nose? 17. Have you ever had your nose broken or a facial fracture? 18. Do you have a problem with job performance due to sleepiness? 19. Do you have a problem driving due to sleepiness? 20. My sleep is frequently disturbed by: (check all that apply) heat choking shortness of breath cold indigestion or heartburn frightening dreams light hunger cough noise thirst chest pain bed partner children pets need to urinate phone asthma creeping, crawling feelings in legs 21. How much of the following fluids do you drink? During a typical day Within 2 hrs of bedtime Coffee: caffeinated cups cups decaffeinated cups cups Tea cups cups Soda glasses glasses Alcohol drinks drinks 22. How much tobacco do you smoke during a 24 hour period? Cigarettes? Cigars? Pipe bowls? 23. Do you use any type of illicit drugs? If so, what?
4 24. Please list the name and dosage of all medications you take NOW or have taken in the last 30 days, including over the counter (non-prescription) medications. 25. Please list any allergies or write NONE. 26. Please check any problem or illness you have now or have had in the past. heart disease headaches depression eye trouble low blood pressure fainting mental problems hearing trouble high blood pressure ringing of the ears muscle cramps pneumonia heart attack black outs ulcers meningitis hernia dizziness prostate trouble heartburn back trouble gout kidney trouble impotence asthma allergies bladder trouble cancer bronchitis seizures arthritis TB thyroid condition 27. Please list any illness not listed above, hospitalizations or surgeries you have had: 28. Do you wear CPAP or BiPAP at home? if yes what company issued your equipment? 29. Do you use oxygen at home? if yes how many hours daily do you use it?
5 Anything you would like to add:
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Sleep Study Information
Sleep Study Information Metroplex Hospital Sleep Center 2111 S. Clear Creek Rd. Killeen, TX 76549 (254) 519-8452 Report to sleep lab at your scheduled appointment time, do not arrive before this time.
SLEEP STUDY CANCELLATION/ NO SHOW POLICY
Olusegun Oseni, MD F.C.C.P. 945 Hilltop Dr, Ste 101 Weatherford, Texas 76068 Phone: 817-594-9993 Fax: 817-594-9915 SLEEP STUDY CANCELLATION/ NO SHOW POLICY Dear Patient: We understand that emergencies
Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
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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).