SLEEP STUDY Patient Name: Date of Birth: Date of Study: This questionnaire involves a broad range of sleep and sleep-related behaviors. Your answers enable us to develop a clearer picture of your sleep/wake cycle. It also helps clarify any sleep problems occurring. It is recommended you complete this survey with the help of a bed-partner or spouse, since some aspects of your sleep behavior may be unknown to you. Your careful attention to questions will help us greatly in your sleep evaluation. Please bring the completed form with you to your initial appointment with us. Nighttime 1. How many hours of sleep are you now getting in a typical night? 2. Do you feel you are currently having a problem with your sleep? Yes No 3. Are you currently having difficulty falling asleep? Yes No If so, please circle if it is? Mild Moderate Severe 4. At what time do you usually go to bed on weekdays? 5. How many minutes does it usually take you to fall asleep? 6. Are you currently having difficulty staying asleep during the night? Yes No If so, please circle if it is? Mild Moderate Severe 7. Do you usually wake up spontaneously for no clear reason? Yes No 8. How long does it usually take to fall back to sleep? 9. Check the things that most often wake you: Noise Cold Movement of bed partner Heat Light Dreams, nightmares Child Different bed or room Aches or pains Others:
10. Check the things that most often wake you in the morning: Alarm clock, etc. Child Bed-Partner Discomfort of body Dream None, ie., wake up automatically 11. Are you currently having a problem with waking too early? Yes No If so, please circle if it is? Mild Moderate Severe 12. Is it usually easy for you to wake up and get out of bed in the morning? Yes No 13. Check the adjectives that best describe how you feel on a typical morning: Depressed Energetic Irritable Alert, awake Refreshed Drowsy, sleepy Other: 14. Are you usually aware you have been dreaming when you wake? Yes No
Nocturnal Behavior 1. Check the following behaviors occurring during your sleep that either you or someone else has noted in the past year: Waking in your sleep Talking in your sleep Bed wetting Asthma Loud snoring Heart palpitations Grinding your teeth Large body jerks Restless sleep Falling out of bed Violent movements Excessive sweating Waking up in terror Waking up with restlessness in legs Rolling or rocking movement Waking up gasping or choking Waking up with chest pains Waking up with hunger Waking up with anxiety or tension Waking up with frightening images Twitching or jerking of legs or arms Waking up with heartburn or gas pains Apnea (lapses in breathing) Shouting, screaming or swearing Waking up with frequent urge to urinate Frequent coughing Waking up with feeling of weight on chest Others: Past History 1. Check the following sleep behaviors that occurred when you were a child or adolescent: Waking in your sleep Bed-wetting Grinding your teeth Twitching or jerking Head banging Breathing difficulties Night terrors, screaming or shouting 2. Did you have any sleeping problems as a child or adolescent? Yes No Daytime
1. Is there any aspect of your daytime activity (work, recreation, leisure, etc.) that is impaired as a result of you sleep/wake problem? Yes No If so, describe: 2. Do you feel drowsy or sleepy at any point during the day? Yes No 3. Do you take any daytime naps? Yes No If yes: How many? What time(s)? How long? 4. Do you feel alert after these naps? Yes No 5. Have you sometimes fallen asleep at work? Yes No 6. Have you had a near accident or accident due to excessive drowsiness? Yes No If yes, describe: 7. Do you ever have sleep attacks during the day ie., periods when you cannot prevent yourself from falling asleep? Yes No
If yes, describe: 8. Do you ever have cataplectic attacks, i.e. episodes when something is triggered and you suddenly feel weak in the legs and/or collapse? Yes No If yes, describe: 9. How many minutes does it take you to get going each morning? (i.e., become fully awake and active)? 10. During which part of the day do you function worst? Morning Evening None in particular Afternoon Late night 11. Is your bedtime usually consistent? Yes No 12. Do you usually fall asleep at your usual bedtime? Yes No 13. When you are away from home do you: Sleep well Have more sleep disturbances 14. Do you have a job which involves shift-working (rotating shifts)? Yes No If yes, does it create difficulties in your sleep/wake habits? Yes No 15. Does any member of your family currently have a sleep problem? Yes No If yes, what kind?
16. Past medical history: Hypertension Heart Disease Stroke Asthma Other 17. Family medical history: 18. Is there any other sleep-related behavior that would be helpful in your sleep evaluation? Yes No If yes, describe: Thank you for your cooperation in answering these questions. Signature: Date: