Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex: M F Neck Size: Smoker: Y N Occupation of Insured: Employer of Insured: Employer Address of Insured: Years at this job: Work Number of Insured: Number & Street City State Zip Code Emergency Contact: Relationship: Phone Number: Referral Source: Physician Newspaper/Magazine Friend Other Referring Physician: Phone Number: Primary Physician: Phone Number: Address: Number & Street City State Zip Code Insurance Company: Phone Number: Address: Number & Street City State Zip Code Group Number: Policy Holder: Medicare Number: Policy Number: DOB of Policy Holder: Medicaid Number: Page 1 of 8
Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations in contrast to just feeling tired? Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Chance of Dozing Sitting and reading 0 1 2 3 Watching TV 0 1 2 3 Sitting inactive in a public place 0 1 2 3 (e.g.: a theatre or meeting) As a passenger in a car for 1 hour 0 1 2 3 without a break Lying down to rest in the afternoon 0 1 2 3 when circumstances permit Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 In a car, while stopped for a few minutes 0 1 2 3 in traffic Total = Page 2 of 8
General Questions I. About Falling Asleep 1. What time do you usually try to go to sleep? A.M. P.M. 2. Does this time vary? Yes No a. If yes, please explain. 3. How long does it usually take you to fall asleep? Hours Minutes 4. While falling asleep, how often do you: Never Sometimes Frequently a. Have thoughts racing through your mind? b. Feel sad or depressed? c. Have anxiety or worry about things? d. Feel muscular tension? e. Feel afraid of not being able to sleep? f. Feel unable to move? g. Have creeping, crawling, aching, or a twitching feeling in your legs? h. Have vivid, dream-like images although you aren t totally asleep? i. Have any kind of pain or discomfort? j. Feel afraid of the dark? k. Suddenly become alert or jerk awake? II. About Your Sleeping Habits 1. How many hours of sleep do you average each night? Hours Minutes 2. How many times do you wake up during the night on average? Times 3. Do you have trouble getting back to sleep? Yes No 4. On a typical night, what is your longest period without sleep? Hours Minutes 5. How long are you awake collectively through the night? Hours Minutes Page 3 of 8
6. How often do you: Never Sometimes Frequently a. Fear you won t return to sleep after waking? b. Sleep with someone in your bed? c. Sleep with pets in your bed? d. Sleep with someone in your room? e. Have restless, disturbed sleep? f. Wake up to tend to children or other pressing issues? g. Feel your heart pounding through the night? h. Sweat profusely through the night? i. Snore loudly? j. Walk in your sleep? k. Talk in your sleep? l. Wake up screaming, violent, or confused? m. Have unusual movements while asleep? n. Wet the bed? o. Have dreams? p. Grind your teeth? q. Fall out of bed? r. Leave a TV or radio on while sleeping? 7. My sleep is frequently disturbed by (circle all that apply): Asthma Nightmares Noise Chest Pain Heat Shortness of breath Indigestion Hunger Thirst Choking Light Cough Cold Need to urinate Gasping Noise or movement of your bed partner Creeping, crawling, or aching in your legs Page 4 of 8
III. IV. About Waking Up 1. What time do you usually wake up? A.M. P.M. 2. What time do you usually get out of bed after your final waking time? A.M. P.M. 3. How often do you: Never Sometimes Frequently a. Depend on an alarm clock to wake up? b. Sleep in for more than an hour? c. Have a hard time waking up? d. Experience vivid, dream-like images although you aren t totally asleep? e. Wake up confused or disoriented? f. Wake up with a headache? g. Feel unable to move after waking? h. Wake up nauseous? i. Wake with a dry mouth? j. Wake up 1 or 2 hours before you have to get up? k. Have difficulty remembering things? About Daytime Functioning 1. How many naps do you take in a normal week? Naps 2. How long is your typical nap? Hours Minutes 3. Are the naps refreshing? Yes No 4. How often do you: Never Sometimes Frequently a. Fall asleep during the day? b. Fall asleep unintentionally? c. Have thoughts racing through your mind? d. Feel sad or depressed? e. Experience anxiety? f. Feel muscular tension? g. Experience muscle weakness while laughing, surprised, angry, excited, etc.? Page 5 of 8
V. Other Questions 1. Does anyone in your family have a sleep disorder? Yes No a. If yes, please explain. Relationship Disorder 2. How much of the following fluids do you consume? In a 24 hour period Within 2 hours of bedtime a) Coffee cups cups b) Coffee, decaffeinated cups cups c) Tea cups cups d) Soda cans cans e) Beer cans cans f) Wine glasses glasses g) Other alcoholic beverages drinks drinks 3. How much tobacco do you use in a 24 hour period? 4. How often do you use: Never Sometimes Frequently a. Stimulants (uppers)? b. Depressants (downers)? c. Narcotics (heroin, morphine, opium, etc)? Page 6 of 8
5. Please list all medications you are taking now and for the past 30 days. Please include any medications you have taken in the past to help you stay awake or go to sleep. Medication Dose Reason 6. How many hours do you exercise or participate in a sport per week? Hours 7. What is your personal opinion as to why you have your particular sleep or waking disorder? VI. Medical History 1. Have you had a previous sleep disorder evaluation? Yes No a. If yes, please list when, where, and findings. 2. Has your weight changed recently? Yes No a. If yes, how much and indicate a gain or loss: 3. Are you or have you ever been directed to use supplemental oxygen therapy? a. If yes, how much? Yes No 4. Please list any hospitalizations and/or surgeries you have had starting with the most recent. Include what you had done, where, and when. (a) (b) (c) (d) Page 7 of 8
Please circle all conditions below that apply to you. General Medical Conditions Arthritis Tuberculosis or TB Exposure COPD Asthma Heart Attack Anxiety Hyper/Hypothyroidism Heart Disease Depression Drug/Alcohol Abuse Seizures High Blood Pressure Heartburn/Acid Reflux Dizziness Stroke Diabetes Headaches Impaired Cognition / Memory Issues Sleep Related Issues Sleep Apnea Sleep Walking Snoring Daytime Hypersomnolence Restless Legs Syndrome Witnessed Apneas Insomnia PLMS/Leg Jerks or Kicks Sleep Talking Non-restorative Sleep Morning Headaches Disruptive Sleep Page 8 of 8