Location South Loop Katy Steeplechase Fort Bend NAME ADDRESS PHONE SEX DOB AGE HEIGHT WEIGHT NECK COLLAR SIZE (inches) Do you have difficulty falling asleep? Is your sleep restless or disturbed? Do you experience frequent or prolonged awakenings? Do you notice noises or disturbances in your sleep environment that cause you to awaken or have difficulty falling asleep? Do you sleep better away from home? Do you become tense or anxious when attempting to go to sleep? Do you relate your sleep problem to a specific change or stress in your life? Have you had recent travel to a high altitude area or do you reside in a high altitude area? If awakened, do you find it necessary to eat or drink in order to resume sleep? Do you use prescription medicines to help you sleep? Do you use non-prescription medicines to help you sleep? If you answered yes to # 10 or # 11 above, please check the medicine used. Ambien (Zolpidem) Ativan (Lorazepan) Klonopin (Clonazepam) Dalmane (Flurazepam) Desyrel (Trazodone) Doxepin (Sinequan) Elavil (Amitriptyline) Halcion (Triazolam) Prosom (Estazolam) Restoril (Temazepam) Valium (Diazepam) Xanax (Alprazolam) Sonata (Zaleplon) Lunesta (Eszopiclone) Other:
Do you use alcohol to help you fall asleep? On average, how much alcohol do you drink per day? (if less than 1 drink per day, enter 0) Cans of Beer: Ounces of Liquor: Do you use any prescription medicines, including diet pills, to help stay alert or awake? Do you use any non-prescription (over-the-counter) medicines, including diet pills, to help maintain an awake or alert state? Do you feel it necessary to consume caffeine product (i.e. coffee, cake, chocolate) to maintain an awake or alert state? On average, how much of the following caffeine products do you drink in a day? (if less than 1 drink per day, enter 0 Glasses of Wine: Cupes of Coffee: Cups of Tea: Cans of caffeinated soft drinks: Are your dreams so real you cannot tell if you are asleep or awake? On occasion, do you awaken soon after going to sleep or in the mornings actually feeling paralyzed, unable to mover or unable to talk, which lasts only a few seconds or minutes? While laughing, or suddenly excite, do you suddenly lose muscle control or lose strength in your legs and feel the need to sit down? Have you suffered a severe head injury, meningitis, or encephalitis in the past year? Do you experience recurrent episodes of strong desires to eat or have sex, lasting for several days (2-3 times/year) in direct association with severe sleepiness? Answer yes if these episodes occur only when sleepy, and the urges resolve when not sleepy If you presently smoke cigarettes, list average number of packs per day If not a current smoke, have you smoked in the past?
Do you have nasal obstruction or sinus problems? Do you snore? Has your weight increased over the past year? Do you wake up at times feeling as if you re are choking or gasping for breath? Do you have headaches upon waking? Has anybody witnessed you stop breathing while you sleep? Do you typically awaken with a dry mouth? Do you typically awaken with a sore throat? Do you have problems with penile erections (i.e. impotence)? Do you experience repetitive arm or leg movements while asleep? Do you have leg and/or arm discomfort when sitting still, or when lying in bed awake; that goes away with movement? (Answer NO if your leg discomfort is muscle cramping) Do you talk in your sleep? Do you grind or clench your teeth while sleeping? Do you sleepwalk? Do you experience episodes of extreme terror or screaming, during sleep, yet have little if any recall of the event? While asleep, have you ever acted out a dream and injured yourself or a bed partner? Do you experience sudden jerky body movements at sleep onset, causing an inability to initiate sleep? Do you have episodes of bed-wetting during sleep? Do you ever wheeze at night? Do you cough at night?
Do you work night shifts Do you work changing shifts? Do you travel across time zones differing by more than two hours, more than once a month? Do you sometimes notice a restricted opening of your mouth upon awakening? Do you have pain in your jaw joint? Do your jaw joints click or pop? How many motor vehicle (include truck) accidents have you been in over the past 1 (one) year? (Include accidents even if you were not at fault) How many motor vehicle (include truck) accidents have you been in over the past 5 (five) years? How many work related injuries, requiring a physician or nurse evaluation, have occurred to you over the past t (one) year? How many work related injuries, requiring a physician or nurse evaluation, have occurred to you over the past 5 (five) years? Approximately how many days of work (or school) have you missed over 1 (one) year? (Check the closest range) t including vacations. Approximately how many days of work (or school) were you late for over the past one year? (Check the closest range) 0 1-2 3-5 6-10 Greater than 10 0 1-2 3-5 6-10 Greater than 10 Have you ever been in an accident, or suffered an injury because you fell asleep? Does your sleepiness affect your performance at work or school? Do you wake rested and refreshed? On weekends or days off, do you sleep more than an hour later than your usual wake-uptime? Do you suffer from extreme daytime sleepiness?
How many times per night do you typically awaken? How long does it typically take you to fall asleep (in minutes)? Approximately, how many hours of sleep do you get most nights? How many hours of sleep would you like to get each night? Typically, how many naps do you take per week? Typically, how long are your naps (in minutes)? Do you have any of the following problems? (Check all that apply) Angina Asthma Back problems (Chronic stiffness or pain) Bad arthritis (Chronic stiffness or pain) Coronary artery bypass surgery Diabetes Emphysema Fibromyalgia syndrome Frequent cough Heartburn (GE reflux) Heart disease High blood pressure Leg cramps while asleep Migraine headaches Parkinson's disease Post-nasal drip Psychiatric disorder Seizure Stroke Thyroid problem hyperthyroid Thyroid problem hypothyroid Wake with food in your mouth Other List all presently used medication (include over the counter drugs, dosages not necessary) 1. 6. 2. 7. 3. 8. 4. 9. 5 10. If you exercise regularly, check the box corresponding to the typical time during the day that you exercise. t typically performed Morning (before 12:00 PM) Afternoon (after 12:00 PM but before 6:00 PM) Evening (after 6:00 PM)
Choose the description that best fits you: (only one choice) Choose the description that best fits you: (only one choice) ** complaints** Always being sleepy Difficulty sleeping (getting to sleep or staying asleep) t being able to sleep at the times desired t getting enough sleep Anxious/Nervous Concerned about problems Content Depressed Overworked Stressed
THE EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just 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 use the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Sitting and reading... Watching TV... Sitting, inactive in a public place (e.g. a theater or a meeting) As a passenger in a car for an hour without a break... Lying down to rest in the afternoon when circumstance permit Sitting and talking to someone... In a car, while stopped for a few minutes in traffic... Chance of Dozing Total Score: