Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. Reason for visit: Abnormal behavior Insomnia Sleep walking Sleep apnea Snoring Sleepiness Narcolepsy Restless leg Please describe your sleep problem: How long ago did this problem begin? Have you ever had any previous evaluations or treatments for this problem? Yes No Sleep study CPAP treatment Surgery Other Are you on any treatment now? Yes; please provide details_ No If treatment was discontinued / failed, please provide reasons What was your weight 10 years ago? (An estimated is fine) Doctor s name and the facility where you had sleep study How do the symptoms affect your daily life? Do you snore? Yes No Duration of Snoring: Unknown Days Weeks Months Years Snore Positions: All positions Left lateral position Right lateral position Supine Bed Partner: Disturbed, sleeping in separate room now Disturbed, but sleeps in same room Not disturbed by snoring I do not have a bed partner Do you stop breathing while sleeping? Yes No If yes, who has witnessed it? Spouse Bed partner Children Friends Other Does your snoring ever wake you up? Yes No If yes, do you wake up with short of breath? Yes No Does snoring embarrass you? (Church, Vacation, Conference) Yes No Are you excessively sleepy during the day? Yes No Do you fall asleep while driving? Yes No Do you dream? Yes No If yes, are they vivid and are you able to recall them? Yes No Page 1 of 6
Do you ever act out your dreams? Yes No Carteret Health Care If yes, Please explain. Do you have any leg discomfort? Yes No Does activity improve this discomfort? Yes No How often does this happen? /week. Is there any one in your family has similar problem? Yes No Have you received treatment for this condition? Yes No If YES, please list all the medications taken. Typical Schedule week days/working days: Bed Time AM/PM Arise at AM/PM Work shift AM/PM Typical Schedule week days/working days: Go to bed at AM/PM Arise at AM/PM Do you have any difficulty initiating sleep? Yes No If yes, what prevents you from falling asleep? At bedtime, thoughts race through my mind Restless leg chronic pain shortness of breath Other How soon do you fall asleep? Do you have difficulty maintaining sleep? Yes No How often do you wake at night? None 1 2 3 4 5 Multiple times Reason for awakening? Urination Headache Unknown Pain Leg cramps Cough Shortness of breath Other Are you able to fall asleep easily after awakenings? Yes No How long does it usually take you to fall asleep after awakenings? minutes/hours. How much sleep do you estimate that you get each night? _ hours. Do you feel refreshed or well rested when you wake up? Yes No Do you take naps during the day? Yes No Page 2 of 6
Carteret Health Care If yes, please provide the frequency. per day/per week. Duration min/hrs Is your nap refreshing? refreshing not refreshing somewhat refreshing Do you sleep: Alone with someone in the same room with someone in the same bed. Has there been a change in your sleep arrangement recently? (Because of death, divorce, illness or other reason). Yes No Is your sleep disturbed because of your bed partner, others in your household or pets? Yes No Besides sleeping, what other activities do you do in the bedroom? Watching TV read eat paperwork exercise other How much of the following do you drink each day? Caffeinated coffee: Cups. What time a day? Caffeinated tea: Cups. What time a day? Caffeinated sodas: Cups. What time a day? Alcoholic beverages: Cups. What time a day? How many packets of cigarettes do you smoke per day? _. Cigars?_.Pipes? How many years have you smoked when did you quit? What kind of exercise you do? What time of the day? How often? What other symptoms do you have? I have restless sleep I have morning headache I have night sweats I have trouble with memory I have trouble concentrating I have chronic pain I have loss of energy I wake up with heart pounding I have anxiety I am irritable I have heart burn while sleeping I kick my legs/jerks my body in sleep I have sore muscles I have confusional arousal I have sleep talking I have sleep walking I have sleep terror I have teeth grinding I have vivid dream-like images (hallucination) when I fall asleep Sometimes I realize I have driven my car to wrong place, and I cannot remember how I did it. Page 3 of 6
Carteret Health Care I get sudden muscle weakness/buckling of knees/dropping jaw/slurred speech when laughing, angry or in situations of strong emotion. I have sleep paralysis I have nightmares I have depression Others Medical History Hypertension Stroke Mood disorders Coronary Artery Disease Heart failure Epilepsy Fibromyalgia Chronic pain Alcohol use Nicotine use GERD COPD/Emphysema Asthma Diabetes Depression Anxiety/Stress Bipolar Schizophrenia Head trauma Headaches Parkinson disease Seizure Anemia Kidney disease Thyroid disease Menopause Cancer Arthritis Others Please list any surgeries, hospitalizations or serious injuries you have had. Are you allergic to any medications? Yes No If yes, please list. Are you taking any medications? Yes If yes, please list. No Medication Strength How often taken Reason Are you single married separated divorced widowed cohabit other What is your occupation? Do you have to do shift work? Yes No If yes, please provide your schedule Family medical history Sleep apnea Insomnia Snoring Restless leg syndrome Narcolepsy Page 4 of 6
Extreme sleepiness Hypertension Carteret Health Care Coronary Artery Disease Others Do you have insomnia? Yes No If the answer is No, please stop. How long have you had the insomnia? What is the pattern of your insomnia? Delayed onset Frequent awakenings at night Early morning awakening Non-restorative sleep Unable able to describe Others_ What time do you usually turn out off bedroom light? Are you bothered by environmental noise at night? Yes No If yes, please explain Do use any of the following devices? White noise machine Earplugs Others Do you describe yourself as a light sleeper? Yes No Do you describe yourself as a night owl? Yes No Are you overly concerned about your inability to sleep? Yes No The more you worry about your sleep, the more agitated you become, and it takes longer time to fall sleep. Do you agree? Yes No Do you sleep better away from your own bedroom, especially when you go on vacation? Yes No List your recent stresses: Moving to new location Personal loss Childbirth Divorce Separation Job change Problem at work Retirement Unemployment Domestic abuse Occupational stress Diagnosis of a new medical condition List remedies tried: OTC sleep aids Benadryl Alcohol Bath before bed Stress reduction techniques Earplugs Exercise Prescription medications Other person's prescription medications Page 5 of 6
Carteret General Hospital Patient Label Carteret Medical Specialists EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations? Rate each description according to your normal way of life in recent times. Even if you have not been in some of these situations recently, try to determine how sleepy you would have been. Use the following scale to choose the best number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Chance of Dozing Sitting and reading Watching TV Sitting inactive in a public place (e.g., a theater or meeting) Sitting as a passenger in a car, for an hour without a break Lying down to rest in the afternoon when your schedule permits it Sitting and talking to someone Sitting quietly after a lunch without alcohol Sitting in a car, while stopped for a few minutes in the traffic Total score (Reference: Johns, MW. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. SLEEP. 1991; 14:540-5) Signature of the patient DATE Page 6 of 6