Intake Questionnaire

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Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK= don t know) On weekdays, when do you usually go to bed? _ and wake up? _ During the weekend, when do you usually go to bed? _ and wake up? _ How long does it take you to fall asleep at night? (Guess is OK) _ Do you have any frequent awakenings during sleep? Y N How often? _ Are awakenings related to needing to use restroom? Y N Have you ever had a sleep study before? Y N DK Do you snore? Y N Please rate from 0-10 the loudness of snoring (0-None, 10-Loud): Have you been informed that you stop breathing or gasp while asleep? Y N DK Do you wake up with a headache in the morning at least once a week? Y N DK Have you had uncomfortable sensations in your legs worsened with prolonged rest or during the evening hours and relieved by movement? Y N DK Do you kick your legs while asleep? Y N DK Have you experienced sudden muscle weakness (e.g. legs, neck) after laughing or strong emotion? Y N DK Have you awoken from sleep able to look around but unable to move or speak for a short time? Y N DK Have you ever seen images, heard sounds, or felt something that was not present when drowsy or upon awakening from sleep? Y N DK Please indicate if any of the following behaviors occur during your sleep (please check all that apply): None apply Sleepwalking Sleep talking/shouting/swearing Frequent nightmares Bedwetting Body jerking Nocturnal cough Dry mouth Heartburn Excessive sweating Awakened with heart palpitations Teeth grinding How many caffeinated beverages do you drink on a typical day?

Do you use recreational drugs? Y N If so, which ones and how often? How many alcoholic beverages do you consume in an average week? Do you use tobacco? How much? _ What is your relationship to the patient? Self Other: Please state briefly the reason for making an appointment: Height: _ Weight: _ Neck Circumference: Surgical/Medical history Psychiatric history Tonsillectomy High blood pressure Suicidal thoughts Deviated nasal septum surgery Atrial fib/cardiac arrhythmias Thoughts of harming others Orthodontia/Braces Congestive heart failure Inpatient hospitalization Sinus surgery GERD/Heartburn Schizophrenia Surgery for sleep apnea/uppp Diabetes mellitus Bipolar disorder Coronary artery bypass Hypothyroidism Depressive disorder Cardiac angioplasty/stents High cholesterol Anxiety disorder Pacemaker / AICD implantation Allergic rhinitis Alcohol/drug dependence Neck surgery COPD Attention deficit-hyperactivity disorder Back surgery Asthma Eating Disorder Stroke/TIA Anemia None Alzheimer s/other dementia Fibromyalgia Other pertinent history (list here) Seizure disorder Parkinson s disease Migraine headache None Other pertinent history (list here)

Family Sleep and Psychiatric History: Place an X next to the relevant answer(s) Sleep apnea Narcolepsy Insomnia Restless Leg Syndrome Depression Anxiety Unknown Other (List here) Father Mother Sister Brother Grandparents Children Please list medications and dosage (including sleep aids and supplements) that you take here (or provide list): Please list allergies or adverse reactions to medications here: Briefly describe what you do for a living and what you like and don t like about it. Highest level of education so far? Grade school Some high school High School Some college Some technical school Technical school diploma Associate s degree Bachelor s degree Master s degree Doctoral degree Do you have children? Y N If yes, how many and what age? List anything else you would like your doctor to know about you.

Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. 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 dose 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Dozing Sitting and Reading Watching TV Sitting, inactive in a public place (e.g. theater, or meeting) As a passenger in a car for an hour without a break Chance of Lying down to rest in the afternoon when circumstances permit Sitting, talking with someone Sitting quietly after a lunch without alcohol In a car, while stopped a few minutes in traffic

Fatigue Severity Scale (FSS) of Sleep Disorders The Fatigue Severity Scale (FSS) is a method of evaluating the impact of fatigue on you. The FSS is a short questionnaire that requires you to rate your level of fatigue. The FSS questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and circle a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to which you agree or disagree that the statement applies to you. A low value (e.g., 1) indicates strong disagreement with the statement, whereas a high value (e.g., 7) indicates strong agreement. It is important that you circle a number (1 to 7) for every question. FSS Questionnaire During the past week, I have found that: Disagree <--------> Agree My motivation is lower when I am fatigued. Exercise brings on my fatigue. I am easily fatigued. Fatigue interferes with my physical functioning. Fatigue causes frequent problems for me. My fatigue prevents sustained physical functioning. Fatigue interferes with carrying out certain duties and responsibilities. Fatigue is among my three most disabling symptoms. Fatigue interferes with my work, family, or social life. Total Score: Copyright Lauren B. Krupps. Reproduced with permission of the author.

Insomnia Severity Index The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. For each question, please CIRCLE the number that best describes your answer. Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s). Insomnia Problem Difficulty falling Asleep Difficulty staying Asleep Problems waking up too early None Mild Moderate Severe Very Severe 4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern? Very Satisfied Satisfied Moderately Dissatisfied Very Dissatisfied 5. How NOTICABLE to others do you think your sleep problem is in terms of impairing the quality of your life? Not at all A little Somewhat Much Very Much 6. How WORRIED/DISTRESSED are you about your current sleep problem? Not at all A little Somewhat Much Very Much 7. What extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY? Not at all A little Somewhat Much Very Much Used via courtesy of www.myhealth.va.gov with permission from Charles M. Morin, Ph.D., Université Laval

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