The Medical Center Sleep Center

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The Medical Center Sleep Center Date: / / Name: Age: (First) (M.I.) (Last) Address: (Street / P.O. Box) (City) (State) (Zip) (County) Phone: Home ( ) Work ( ) Date of Birth: / / Education: Marital Status: Height: Weight: Social Security #: Spouse's Name: In Case of Emergency Contact: (Name) (Phone) (Relation) Pt. Place of Employment: (Phone) Occupation: Referring Physician: Physician's Address: It is important for you to be as accurate as possible in answering the following questions. The purpose of this questionnaire is to get a total picture of your background and the nature of your present problem. Please complete these questions as thoroughly as you can. THIS INFORMATION WILL BE HELD IN THE STRICTEST CONFIDENCE Page 1 707009 (10902) NEW 2/07

A. PRESENT ILLNESS: The Medical Center Sleep Center 1. How do you describe your sleep problem? Check all that apply to you. ( ) breathing irregular during sleep ( ) falling asleep ( ) staying asleep ( ) waking up ( ) staying awake ( ) snoring ( ) legs jerking during sleep ( ) all of the above ( ) other 2. How long has this problem bothered you? ( ) since childhood ( ) since teenage years ( ) since the start of adult life 3. On the scale below, estimate the severity of your sleep problem. mild moderate severe very severe totally incapacitation 4. Yesterday, how much coffee with caffeine did you drink? ( ) none ( ) one or two cups ( ) less than a pot ( ) more than a pot 5. Yesterday, how many soft drinks with caffeine did you have? ( ) none ( ) one or two cans or bottles ( ) less than six cans 6. Yesterday, how much tea with caffeine did you drink? ( ) none ( ) one or two glasses ( ) less than a quart ( ) more than a quart 7. Yesterday, how much alcohol did you drink? ( ) none ( ) a few beers ( ) more than a 6 pack of beer ( ) one or two glasses of wine ( ) more than a glass or two of wine ( ) a shot or two of hard liquor ( ) more than two shots of hard liquor 8. Yesterday, how much tobacco did you smoke? ( ) none ( ) less than a pack ( ) two/three packs ( ) more than two or three packs 9. Yesterday, did you take any over the counter medications? ( ) yes Please list: 10. Yesterday, did you lie down to take a nap? ( ) yes ( ) no nap When did it start: How long did it last? 11. Yesterday, did you take a medicine to help you go to sleep? ( ) yes ( ) no What was the name & amount? When did you take it last? Page 2 707009 (10903) NEW 2/07

12. Yesterday, what time did you GET IN THE BED? 13. Yesterday, when were the LIGHTS TURNED OFF? 14. Last night, how long did it take to fall asleep? 15. Last night, how many times did you wake up? 16. Last night, do you think you SNORED? ( ) yes ( ) no ( ) maybe ( ) don't know or don't remember 17. Last night, do you think your legs jerked or kicked? ( ) yes ( ) no ( ) maybe ( ) don't know or don't remember 18. This morning, when did you finally WAKE UP in the bed? 19. This morning, when did you finally GET OUT of the bed? 20. This morning, what woke you up or caused you to wake up? ( ) alarm clock ( ) person or child ( ) spontaneously ( ) baby crying ( ) animal or pet ( ) door bell ( ) machinery ( ) noise 21. Generally, do you take any medicine to stay awake? ( ) yes ( ) no Name & Amount: What time of day: 22. Generally, do you take naps ( ) yes ( ) no What time of day: 23. Generally, what time do you GET INTO THE BED? 24. Generally, when are the LIGHTS TURNED OFF? 25. Generally, how long does it take to fall asleep after getting in bed? 26. Generally, how many times do you wake up during sleep? 27. Generally, what time do you wake up? 28. In the last month or so, how many hours has been the SHORTEST sleep? 29. In the last month or so, how many hours has been the AVERAGE sleep? 30. In the last month, how many hours has been the LONGEST sleep? Page 3 707009 (10904) NEW 2/07

31. Generally, how do you sleep? ( ) very good ( ) good ( ) fair ( ) badly 32. What is the best time of the day for mental alertness for you? ( ) early morning ( ) mid morning ( ) afternoon ( ) evening ( ) night ( ) not any B. PAST MEDICAL HISTORY 33. Do you take any kind of medication? If so, please list Reason Name Amount (mg) How Often 34. Do you take any over the counter medications? If so, please list Reason Name Amount (mg) How Often ARE YOU ALLERGIC TO ANY MEDICATIONS? ( ) yes ( ) no if yes, please list each medication: 35. Do you have irregular heart beat problems? 36. Have you ever had any kind of stroke? 37. Have you ever had a seizure or do you have epilepsy? 38. Have you ever been diagnosed with any type of sleep disease? ( ) yes if yes, any type of treatment? ( ) no ( ) unsure 39. Do you have a pacemaker? 40. Have your tonsils taken out? 41. Have you ever had surgery on your soft palate of your mouth? Page 4 707009 (10905) NEW 2/07

42. Have you ever had a sleep study? 43. Do any members of your family have the following medical conditions? Snoring Chronic sleep problems Sleep study or using CPAP High blood pressure Stroke Heart disease Muscle disease Severe, lifelong headaches 44. Is your work shift the same from day to day or does it vary? 45. Rate your work situation: ( ) stressful ( ) satisfactory ( ) excellent 46. Do you have shortness of breath at night? Please note how often you... 47. Sleep better away from home? 48. Fall asleep watching T.V.? 49. Fall asleep reading? 50. Take long naps and still feel tired? 51. Had daytime sleepiness as a child or teenager? 52. Feel paralyzed when falling asleep? 53. Feel paralyzed when waking up? Page 5 707009 (10906) NEW 2/07

54. Nearly collapse when extremely emotional? 55. Nearly collapse when laughing or crying? 56. Experience dreams when falling asleep or waking up? 57. Feel refreshed after a short (10 or 15 minute) nap? 58. Do you snore? 59. Do you snore sitting in a chair? 60. Do you snore so loudly that your bed partner sleeps elsewhere? 61. Do you suddenly wake up gasping for air? 62. Do you sweat a lot at night? 63. Feeling crawling sensations in legs at night? 64. Feel aching or burning in legs at night? 65. Notice your legs jerking or kick during the night? 66. Awaken confused for awhile? 67. Awaken with a scream or cry? 68. Awaken frightened by a dream or nightmare? Page 6 707009 (10907) NEW 2/07

69. Talk in your sleep? 70. Walk in your sleep? 71. Have violent or injurious behavior during sleep? 72. Grind teeth during sleep? 73. Wet the bed in sleep? 74. Do you sleep with several pillows? 75. Awaken at night with belching or heartburn? 76. Have trouble with early morning awakening? 77. Have trouble with going to sleep? 78. Feel tired even after a good night of sleep? 79. Have less desire for social encounters, fun or humor? 80. Have less appetite for food? 81. Do you feel depressed? Page 7 707009 (10908) NEW 2/07

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