Date of birth: Today s date: Dear Patient: SLEEP HISTORY QUESTIONNAIRE Thank you for taking the time to fill out a sleep history questionnaire. This will help our healthcare team to provide the best possible care for you. Please write clearly and answer all questions that apply. Have you been evaluated for a sleep disorder before? If so, when? Month: Year: Have you previously had a sleep study? Please describe your problem(s) related to sleep or sleepiness. How long have you had this problem? What has been tried so far to help you with your problem? Was it effective? Do you snore? Sometimes If you answered yes or sometimes, please complete section below regarding snoring quality. Please CHECK ALL THAT APPLY to your snoring: Volume described as: Soft Moderate Loud Very loud Frequency: Continuous Intermittent Variable Present in all positions Worse on back Impact: Bothers bed partner or others Disrupts your bed partner s sleep Has anyone ever commented that you do any of the following? Hold your breath in your sleep Breathe irregularly in your sleep No one has commented that they noticed anything odd with my sleep breathing ; Revised 9/26/16; Next review due 9/26/19 Page 1 of 7
Do you have any of the following issues? Yes No Nasal congestion Allergies Dry mouth Wake up gasping Wake up choking Morning headaches Wake up breathless Acid reflux or Gastroesophageal Reflux Disease (GERD) Any additional comments about your sleep breathing? Tell us about your sleep and work schedule. Are you currently working? t currently working Retired What is your work shift? Days Evenings Nights Steady Variable Rotating Typically what days of the week do you work? What is your sleep schedule? Bedtime What time do you go to sleep? How long in minutes until you fall asleep? What time do you get up? Do you use an alarm clock? How much time in bed? How much time sleeping? How many times do you wake? Reason for waking? Do you wake to urinate? Mon Tues Wed Thurs Fri Sat Sun Work days Check if not applicable Non work days Check if same as work day Do you nap? If yes, what time of day? For how long? Hours How many days a week do you nap? Do you dream during naps? Are your naps refreshing? Is your nap schedule the same on working days? Not applicable Any additional comments regarding your naps? Page 2 of 7
Motor Activity/Restless Legs Do you notice problems with leg twitching or kicking in your sleep? Has anyone else noticed problems with you twitching or kicking in sleep? Does your leg twitching or kicking disrupt your sleep? Do your legs ever have a creepy crawly feeling or general feeling of discomfort or uneasiness while sitting or lying quietly? If you answered yes, when and how severe is the discomfort? Evening Daytime Mild Moderate Severe Do these sensations disrupt your sleep? Symptoms noticed in Arms Legs Does the discomfort improve with movement? Any additional comments regarding restless legs? Do you have problems with any of the following? Sleep talking Sleepwalking Grinding teeth Clenching jaw Recurrent nightmares Acting out dreams Any additional comments regarding the above questions? Have you experienced sudden muscle weakness from strong emotions/activities? If yes, which emotions? Laughter Surprise Anger Exercise Have you ever experienced either of the following? An inability to move (sensation of paralysis) when waking or falling asleep? Dream-like hallucinations or sounds/voices when waking, falling asleep or napping? Any additional comments regarding the above questions? Page 3 of 7
Epworth score: How likely are you to doze off or fall asleep in the following situations? You should rate your likelihood to doze off, not just feeling tired. Use the following numeric scale: 0 = No chance of dozing 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Sitting and reading Watching television Sitting, inactive in a public place Passenger in a car for 1 hour without break Lying down to rest in the afternoon Sitting talking with someone Sitting quietly after lunch without alcohol In a car while stopped a few minutes in traffic Total: Likelihood of dozing (0-3) Sleepiness occurs when: Reading Watching television In meetings Using a computer At work In the morning In the afternoon In the evening Do you have sleepiness when driving? Never Occasionally (a few times a year) Frequently (once a month or more) Morning driving Afternoon driving Evening driving Sleepiness impacts my: Memory Concentration Mood Focus Has sleepiness while driving caused you to ever: Hit the rumble strip Cross the center line Have a near miss Have an accident Please include any comments regarding your sleepiness: Page 4 of 7
If you have problems with insomnia (difficulty falling asleep or staying asleep), please answer the following questions. What kind of activities do you engage in prior to bedtime (last 2-3 hours before bed)? Describe your level of sleepiness prior to bedtime? What are your reasons for not being able to fall asleep, or stay asleep? How much time do you spend in bed if you are unable to sleep? If I cannot fall asleep, I typically: Stay in bed Read in bed Watch TV in bed Watch TV elsewhere Watch clock Have a busy mind Get anxious/stressed Get out of bed Practice visualization Try to relax My sleep environment is: Quiet Noisy Dark Bright, or not dark enough Cool Warm Comfortable bed Uncomfortable bed Pets in room Partner noisy Partner s movements disrupt sleep How much time does it take to fall back to sleep if you wake? Any further comments regarding insomnia? Page 5 of 7
This last page will ask you questions about your social/medical history. Do you now have, or have you had in the last year: Excessive sleepiness Edema (fluid retention) in legs History of head injury Non-restorative sleep Hypertension Memory problems Disrupted sleep Shortness of breath climbing stairs Restless legs Fatigue Breathlessness lying flat Headaches on awakening Weight loss Asthma Depression Weight gain Nighttime coughing Anxiety Night sweats Nighttime wheezing Insomnia Arousals from sleep Disruptive snoring Difficulty paying attention History of anemia Heartburn Cold intolerance Nasal congestion Acid reflux Heat intolerance Nasal obstruction Regurgitation (vomiting) Seasonal allergies Chest pain with exertion Back pain disrupting sleep Environmental allergies Palpitations Joint pain disrupting sleep Runny/stuff nose Shortness of breath walking Muscle cramps Watery/itchy eyes Shortness of breath at night Seizures What is your height? feet inches What is your current weight? pounds Weight one year ago? pounds Maximum weight? pounds Occupation? Do you currently smoke? How many packs per day? Cigars, other Have you smoked in the past? How many packs per day? E-cigarettes Date quit: How many alcoholic beverages do you consume on average per day? How many caffeinated beverages do you consume on average per day? After 4pm? Do you exercise? How many times per week? What kind of exercise? Any hobbies? Marital status? Children? Any past surgeries? Any significant past or present medical problems that you received treatment for? Any significant family history of important medical problems? Page 6 of 7
Please list your medications for us: If you are currently a patient of the Concord Hospital Medical Group, you may skip this step. Medication Dose Instructions Page 7 of 7