Original Sleep Hygiene Rules* 1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing time in bed a bit seems to solidify sleep; excessively long times in bed seem related to fragmented and shallow sleep. 2. A regular arousal time in the morning seems to strengthen circadian cycling and, finally, to lead to regular times of sleep onset. 3. A steady daily amount of exercise probably deepens sleep over the long run, but occasional one-shot exercise does not directly influence sleep during the following night. 4. Occasional loud noises (eg, aircraft flyovers) disturb sleep even in people who do not awaken because of the noises, and individuals cannot remember them in the morning. Sound attenuation in the bedroom might be advisable for people who must sleep close to excessive noise. 5. Although an excessively warm room disturbs sleep, there is no evidence that an excessively cold room solidifies sleep, as has been claimed. 6. Hunger may disturb sleep. A light bedtime snack (especially warm milk or similar drink) seems to help many individuals sleep. 7. An occasional sleeping pill may be of some benefit, but the chronic use of hypnotics is ineffective, at most, and detrimental in some insomniacs.
8. Caffeine in the evening disturbs sleep, even in persons who do not feel it does. 9. Alcohol helps tense people to fall asleep fast, but the ensuing sleep is then fragmented. 10. Rather than trying harder and harder to fall asleep during a poor night, switching on the light and doing something else may help the individual who feels angry, frustrated, or tense about being unable to sleep. *Adapted from Hauri.23
REM SLEEP DIAGNOSTICS & RESEARCH CENTER 3334 GREYSTONE WAY VALDOSTA, GA 31605 229-249-9920 PATIENT NAME: AGE: SEX: HEIGHT: WEIGHT: NECK SIZE: PATIENT EDUCATION AND SCREENING QUESTIONNAIRE Do you have any questions about the test? Do you have any special requests or services required during your sleep test? If we need to contact you in the future, can we leave a phone message at home? Yes No Do you go to bed at a regular time every night? Yes No What time? Do you wake up at a regular time every time every day? Yes No What time? On the average, how many hours do you spend in your bed each night? On the average, how many hours do you sleep each night? How long does it normally take for you to fall asleep after bedtime? While in bed, do you read? Yes No and/or watch TV? Yes No Do you take naps? Yes No If so, what times? For how long? Do you smoke? Yes No How much? How long? Do you drink alcohol? Yes No What/how much/how often/time of day? Do you use caffeine? Yes No What/how much/how often/time of day? Has anyone observed you snoring? Yes No Not sure If yes, do you snore every night? Yes No Not sure
On a scale of 1-10, 10 being best the loudest, how loud do you snore? Has anyone observed you having pauses in your breathing at night? Yes No How long do these pauses last? How long has this occurred? Do you have daytime sleepiness Yes No and/or fatigue? Yes No Do you have leg jerks at night? Yes No Do you have morning headaches? Yes No Do you have shortness of breath at night? Yes No Do you have night sweats? Yes No Do you wake with a sore throat? Y or N Dry mouth? Y or N Nasal congestion? Y or N Has your bed partner been forced into another room because of your snoring? Yes No Have you experienced impotence or decreased libido? Yes No Do you have difficulty driving due to your sleepiness? Yes No Have you ever fallen asleep while driving? Yes No How many times? Is your weight stable? Yes No Have you gained weight or lost weight? # of pounds Over what course of time? Do you wet the bed (enuresis)? Yes No Do you have difficulty falling or staying asleep? Please specify. Does chronic pain interfere with your sleep? Yes No On a scale of 1-10, 10 being most severe, rate your pain Why do you have pain? Do you have difficulty sleeping away from home? Yes No Do you have hallucinations while falling asleep or upon awakening? Yes No Do you ever have sudden unexplained, involuntary or inappropriate sleep attacks? Yes No Do you dream during these attacks? Yes No Do you have total body paralysis while falling asleep or upon awakening? Yes No
Do you have severe muscular weakness elicited by strong emotions (cataplexy)? Yes No Has your nose ever been broken? Yes No Do you have a deviated septum? Yes No Have your Tonsils been removed Yes No No Have your Adenoids been removed? Yes Have you had surgery to remove the uvula (UPPP)? Yes No Have you had any other nasal or throat surgery? Yes No Explain Do you have Gastroesophageal Reflux Disorder (GERD)? Y or N High blood pressure? Y or N (Hypertension) Chronic Obstructive Pulmonary Disease? Y or N Asthma? Y or N Diabetes? Y or N Depression? Y or N Do you have any drug allergies? Do you have any additional comments or observations? EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations: SCALE: 0 = WOULD NEVER DOZE 1 = SLIGHT CHANCE 2 = MODERATE CHANCE 3 = HIGH CHANCE SITUATIONS SCALE Sitting and talking to someone 0 1 2 3 Sitting inactive in a public place 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 Sitting and reading 0 1 2 3 Watching television 0 1 2 3 Lying down to rest in the afternoon 0 1 2 3 In a car while stopped in traffic 0 1 2 3 As a passenger in a car 0 1 2 3
SEVERITY OF DAYTIME SLEEPINESS SCALE MILD: Unwanted sleepiness or involuntary sleep episodes occur during activities that require little attention. Examples include sleepiness that is likely to occur while watching television, reading, or traveling as a passenger. Symptoms produce only minor impairment of social or occupational function. MODERATE: Unwanted sleepiness or involuntary sleep episodes occur during activities that require some attention. Examples include uncontrollable sleepiness that is likely to occur while attending activities such as concerts, meetings, or presentations. Symptoms produce moderate impairment of social or occupational function. SEVERE: Unwanted sleepiness or involuntary sleep episodes occur during activities that require more active attention. Examples include uncontrollable sleepiness while eating, during conversation, walking, or driving. Symptoms produce marked impairment in social or occupational function. Is your level of sleepiness: None? Mild? Moderate? Severe? * Refer to Sleepiness Scale above. Please list all medications you are currently taking below or provide a list that can be copied. Include Non-Prescription drugs and Vitamins. Name of medication Dose-mg/day and time of day taken How long have you taken medication? Reason you are taking medication Sleep Physician Signature Date
Standard Interview Format for the Evaluation of Insomnia Definition of the Problem 1. What time do you go to bed? What time is your final awakening? 2. How long does it take you to fall asleep? 3. Do you awaken during the night? If yes, how many times? 4. How much total sleep time do you get? 5. How much total sleep time do you need to feel rested? 6. How long have you had this sleep pattern? 7. What was your sleep like before you developed this problem? 8. What treatments have you tried for your sleep problem? 9. Did any of these treatments help? Behavioral Insomnia 10. Do you watch television, read, work, or eat during the night? In bed? 11. How do you sleep away from home (e.g., on vacation)? 12. Do you fall asleep more easily on the couch than in the bed? 13. Are you easily awakened by noise or light? 14. What do you do while awake at night? 15. Was there a precipitating event when your insomnia first began (e.g., hospitalization, stressful event)? 16. Do you take naps during the day? 17. Do you look at the clock during the night? Cognitive Features 18. Do you feel frustrated or tense when seeing your bed or bedroom? 19. Do you think about your sleep difficulty during the day? 20. Are you afraid of not sleeping? What do you think will happen to you? 21. How does difficulty sleeping affect your life? Medical 22. Do you have any medical problems? (Review of systems) 23. Do you have any pain at night?\ 24. What medications do you take? What dosages? How often? ETOH/Drugs 25. Do you drink alcohol? How much? How often? 26. Do you take any non-prescribed drugs? Diet pills? 27. Have you tried medication for your sleep problem? 28. How much coffee do you drink?
Restless Legs / Periodic Leg Movements 29. Have you noticed muscle twitches in your legs at night? 30. Do you ever have painful or itching sensations in your legs that prevent you from sleeping? 31. Has your bed partner ever noticed leg movements while you were sleeping? Sleep-Disordered Breathing 32. Do you snore? 33. Do you ever awaken gasping for breath? 34. Has your bed partner noticed any unusual breathing pattern? 35. Do you have any difficulty breathing through your nose? 36. Have you ever had surgery on your nose or throat? Psychiatric 37. Have you ever been treated for emotional or psychological problems? 38. Have you felt depressed recently? 39. How is your appetite? Has your weight changed lately? How much? 40. Do you have any phobias? Panic attacks? 41. How is your marriage? Does your spouse understand the problems you have been having with your sleep? 42. Do you have an active sex life? Does this affect your ability to sleep? 43. Do you have a stressful job? Stressful life? Circadian Rhythms 44. Do you find it difficult to get out of bed in the morning? 45. Do you sleep later on weekends (or days off)? 46. What are your work hours? 47. Do you ever change work shifts? Daytime Sequelae / Misc 48. How does poor sleep interfere with your performance the following day? 49. Is your job performance affected? 50. Do you fall asleep at unexpected times during the day? 51. What would you like to see changed about your sleep? 52. How would improved sleep affect your daytime functioning? 53. Do any family members have insomnia, excessive sleepiness, or another sleep disorder? 54. Do you and your bed partner have similar bedtimes? 55. Does your sleep ever improve under certain circumstances?
TWO WEEK SLEEP DIARY INSTRUCTIONS: 1. Write the date, day of the week, and type of day: Work, School, Day Off, or Vacation. 2. Put the letter C in the box when you have coffee, cola or tea. Put M when you take any medicine. Put A when you drink alcohol. Put E when you exercise. 3. Put a line (l) to show when you go to bed. Shade in the box that shows when you think you fell asleep. 4. Shade in all the boxes that show when you are asleep at night or when you take a nap during the day. 5. Leave boxes unshaded to show when you wake up at night and when you are awake during the day. SAMPLE ENTRY BELOW: On a Monday when I worked, I jogged on my lunch break at 1 PM, had a glass of wine with dinner at 6 PM, fell asleep watching TV from 7 to 8 PM, went to bed at 10:30 PM, fell asleep around Midnight, woke up and couldn t got back to sleep at about 4 AM, went back to sleep from 5 to 7 AM, and had coffee and medicine at 7:00 in the morning. Today s Date Day of the week Type of Day Work, School, Off, Vacation Noon 1PM week 2 week 1 2 sample Mon. Work E A I 3 4 5 6PM 7 8 9 10 11PM Midnight 1AM 2 3 4 5 6AM 7 C M 8 9 10 11AM