SLEEP & MEDICAL HISTORY QUESTIONNAIRE Patient Name Sex Age Date Please complete the following questionnaire by placing a check in the appropriate areas and filling in the blanks. My Main Sleep Complaint(s) Is: Trouble sleeping at night for how many months/years? being sleepy all day for how many months/years? snoring for how many months/years? unwanted behaviors during sleep, explain other, explain Sleep Pattern: Weekdays(Work Days) Weekends(Off Days) Typical bedtime: Typical time required to fall asleep: Type of activities done during nighttime awakenings (restroom, TV, read, eat): Typical time required to fall back asleep after awakening: Typical wake up time: Desired wake up time: How do you usually awaken (alarm clock, pets, bed partner): Typical time you get up: Total amount of sleep per night: Number of naps per day: 1
Please check all of the following statements that are true about your sleep: Sleep Habits I usually sleep alone:, or I sleep with a partner pets children I share a bedroom, but have separate beds I share a dwelling, but have separate bedrooms My sleep disturbance is problematic to my relationship with my bed partner My sleep disturbance affects my bed partner s sleep I usually watch TV or read in bed prior to sleep I frequently travel across two or more time zones I drink alcohol prior to bedtime I drink caffeinated beverages in the evening I smoke prior to bedtime or when I awaken during the night I eat a snack at bedtime I eat if I awaken during the night I typically awaken to urinate during the night I have trouble falling asleep I awaken frequently during the night I am unable to return to sleep easily if I awaken during the night Thoughts start racing through my mind when I try to fall asleep I awaken early in the morning, still tired but unable to return to sleep I have nightmares as an adult I experience a creeping-crawling, or tingling sensation in my legs when I try to fall asleep I sweat a great deal during sleep I cannot sleep on my back 2
Breathing I have been told that I stop breathing while I sleep I awaken at night choking, smothering, or gasping for air I have been told that I snore I have been told that I snore only when sleeping on my back I have been awakened by my own snoring Restlessness I am a restless sleeper I kick or jerk my legs and/or arms when I sleep I experience restlessness, tingling, or crawling in my arms or legs I experience an inability to keep my legs still prior to falling asleep I talk in my sleep as an adult I have sleep walked as an adult I grind my teeth in my sleep Daytime Sleepiness I take daytime naps I have a tendency to fall asleep during the day I have experienced lapses in time or blackouts I have fallen asleep while driving I have had an auto accident as a result of falling asleep while driving I have had an accident while operating heavy machinery or equipment as a result of falling asleep 3
I have had injuries as a result of sleepiness I fall asleep while watching TV I fall asleep during conversations I fall asleep in sedentary situations I performed poorly in school because of sleepiness I have experienced sudden muscle weakness in response to emotions such as laughter, anger, or surprise I have experienced an inability to move while falling asleep or waking up I have experienced hallucinations, dreamlike images, or sounds while falling asleep or waking up Medical History What is your: Height? Weight? What was your weight one year ago? For women: Pregnant? Yes No If yes, due date? Five years ago? Any pregnancy complications? Describe Complications in previous pregnancies? Describe Premenopausal Birth Control? Describe Are your cycles fairly regular Yes No Postmenopausal Hormone Replacement? Describe Bioidentical Hormones Describe 4
Past Sleep Evaluation & Treatment: I have had a previous sleep disorder evaluation I have had a previous overnight sleep study I have had daytime nap studies I have been prescribed a CPAP or bi-level machine for home use I have had surgical treatment for a sleep disorder I have previously been treated for a sleep disorder I have previously been prescribed medication for a sleep disorder Please list the name of any pill that you have taken in the past for a sleeping disorder, i.e. insomnia, daytime drowsiness, restless legs: Name Did it help? Yes No Yes No General Medical History: Anemia Abnormal bleeding Fibromyalgia Arthritis Anxiety Depression Post Traumatic Stress Disorder Asthma/COPD/emphysema Bronchitis Allergies/Hay fever Congenital defect/disorder Alcoholism Drug dependence Migraine Seizures Heart attack Heart Disease/Failure Heart Arrhythmia High Blood Pressure High cholesterol Chest pain Dizziness/fainting 5
Diabetes Stroke Cancer Parkinson s Disease Prostate disease Urinary disorder Gynecologic disorder Other (describe below) Hepatitis Liver diseases Reflux/Ulcer Thyroid disease Positive TB skin test Tuberculosis Valley Fever Surgical History: List surgeries and year Family History: Please check all that apply and indicate who was affected Sleep Apnea Obesity High Blood Pressure Heart Attack Stroke Diabetes Insomnia Anxiety/Depression Thyroid Disease Narcolepsy Restless Legs Bleeding Disorder Sleepwalking Epilepsy Cancer (type) 6
Social History: Marital Status: single married divorced separated widowed Occupation Do you operate heavy machinery or dangerous equipment at work or involving a hobby or sport? yes no Do you fly an airplane? yes no Are you a commercial: truck driver pilot train operator tractor/crane/forklift, etc. operator Sports/Hobbies Exercise routine/frequency Have you ever smoked? yes no If you quit, when? # years smoked #packs/day Do you currently smoke? yes no if yes, cigarettes cigars pipe amount per day #years Do you drink alcohol? yes no if yes, what type? beer wine hard liquor #drinks/day #drinks/week #drinks/month Do you use recreational drugs? previously currently describe Caffeine Use: coffee/tea soda energy drinks drinks per day 7
Medications: Name Strength(i.e. mg) Frequency(i.e. every morning) Allergies : Type (i.e. name of drug, environmental, latex, peanuts) Reaction (rash, swelling) 8