Last and first names: F M Date: Date of birth: / / YYYY MM DD Weight: kg /lbs Profession/job: Height: _ cm /ft.in. BMI:_ Family physician : ANC (adjusted neck circumference) : Neck circumference (cm) Hypertension + 4 cm Snoring + 3 cm Witnessed apnea + 3cm Total STOP QUESTIONNAIRE = /4 Snoring Oui Non Observed apnea Oui Non Tiredness, sleepiness Oui Non High blood pressure Oui Non YOUR EXPECTATIONS MEDICATION list enclosed Name Concentration Time of the day PERSONNAL HISTORY Angina/Heart attack If yes, what year? Chronic bronchitis, emphysema or asthma If yes, what year? Nose, lacrimal sac or throat surgery If yes, what year? If yes, specify Depression If yes, what year? Diabetes If yes, how many years? Fibromyalgia If yes, how many years? Hypertension (known or treated) If yes, how many years? Heart failure If yes, how many years? Kidney failure If yes, how many years? Stroke (cerebrovascular accident) If yes, what year? Other : SOM-DOC-014 V9.0 Page 1 sur 6
LIFESTYLE HABITS Smoke: Do you smoke? Have you ever smoked? If you answered YES to either question, how many cigarettes a day? If you answered YES to either question, for how many years? For ex-smokers, the year in which you stopped : Alcohol : Do you drink alcohol on a regular basis? (wine, beer, liquors) If yes, noon dinner evening How much per day : Stimulants : Coffee /day Tea /day Cola: /day Energy drinks /day Chocolate /day Drugs : if yes, which one(s) SLEEPING HABITS Work schedule Day Evening Night Variable schedule You sleep an average of hours per night. When you wake up, you feel: Tired not very rested Rested It varies When you work or go to school, generally speaking your schedule is as follows: Go to bed: am/pm Fall asleep am/pm Wake up: am/pm Get up: am/pm When you are on vacations and on weekends, generally speaking, your schedule is as follows: Go to bed: am/pm Fall asleep am/pm Wake up: am/pm Get up: am/pm Are you «early bird» ou «night owl»? an absolute early bird more night owl than an early bird more an early bird than a night owl an absolute night owl To be in good mental and physical shape, you need hours of sleep; ideally, you would go to bed at h and get up at h. What was your longest night of sleep (timewise) in the last month? hours Do you take medication to sleep (prescription or over the counter)? days/wk Do you drink alcohol to help yourself sleep? days/wk Do you do physical exercises within two hours before going to bed? days/wk Is your sleep disturbed by light, noise, the weather or your partner? days/wk Do you set aside time to relax before going to bed? days/wk Do you read or watch television in bed? days/wk Are you awake in bed for more than one hour? days/wk SOM-DOC-014 V9.0 Page 2 sur 6
Generally speaking, do you take naps? One or more times a day A few times a month A few times a week Very rarely Average length of your naps Most of your naps happen in: The morning The afternoon Early in the evening After taking a nap, you feel : More tired Very rested A little rested No different SYMPTOMS Are you ever bothered by sleepiness during the daytime (you feel like sleeping and have to struggle to stay awake)? 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 haven t done some of these things recently, try to imagine how they would have affected you. Using the following scale to choose 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 Situations Scores (0, 1, 2 or 3) Sitting and reading Watching TV Sitting, inactive in a public place (e.g. theatre, meeting) As a passenger in a car for an hour without break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped in traffic for a few minutes Motor vehicle accidents Have you ever fallen asleep at the wheel? Have you ever had a motor vehicle accident when you were driving because of sleepiness? How many car accidents have you had while driving, over the past 5 years? Total : How often do you feel sleepy at the wheel? (Check only one answer.) 7 days a week 4 to 6 days a week 1 to 3 days a week 1 to 3 days a month less than 1 day a month Never SOM-DOC-014 V9.0 Page 3 sur 6
Do you have the following symptoms? Headaches upon awakening Sexual performance problems (drop in libido, impotence) Stuffy nose Urge to urinate at night Restless sleep Night sweats Non-restorative sleep Fatigue (not sleepiness) Poor concentration or memory Poorer school or work performance Irritability or mood swings, interpersonal difficulties Drop in motivation, energy or initiative Accident (or near-missed) on the road or at work Worry or obsessive thinking about or during sleep times/wk. times/wk. times/night times/wk. times/wk. times/wk. times/month times/wk. You started experiencing sleepiness or these symptoms in the month of _ in the year Your sleepiness or symptoms are worse : In the spring In the summer In the fall In the winter No changes with the seasons Can you identify one or more factors that triggered all your symptoms? If yes, specify: Since they began, your symptoms have increased have diminished have not changed SLEEP APNEA Do you snore? Don t know never or almost never Sometimes Often Always or almost always Position in which you snore most: On the back In any position Don t know Does your snoring bother those who are near you? Do you sleep in a separate bedroom because of your snoring? Have you been told that you stop breathing when you are sleeping? On the back In any position Don t know Do you ever wake up gasping for air? SOM-DOC-014 V9.0 Page 4 sur 6
INSOMNIA For each question below, please circle the number that best describes your sleep pattern during the past month. Please estimate the level of severity of the different types of insomnia that apply to you : None Slight Moderate High Extreme Problems falling asleep. 0 1 2 3 4 Problems staying asleep. 0 1 2 3 4 Problems waking up too early in the morning. 0 1 2 3 4 How satisfied are you with the sleep you currently get? Very satisfied Satisfied Indifferent Unsatisfied To what degree would you say that your sleep problems interfere with your functioning (e.g.fatigue, concentration, memory, mood)? Very unsatisfied 0 1 2 3 4 To what degree would you say that your sleep problems are apparent to others in terms of a deterioration in quality of life? 0 1 2 3 4 To what degree are you worried or concerned about your current sleeping problems? 0 1 2 3 4 RESTLESS LEG SYNDROME Do you often feel an irresistible urge to move your legs (because of crawling, sharp shooting or prickly sensations, etc) when you are immobile? Does this prevent you from sleeping? If yes, times a week for minutes on average These sensations are worse in the Morning Afternoon Evening Bedtime No difference These are alleviated By resting By walking Nothing alleviates them Has anyone ever told you that you often move your legs when you are sleeping? Do you ever have painful cramps in your feet or legs at night? Do you grind or clench your teeth at night or have pain in your jaw in the morning? SOM-DOC-014 V9.0 Page 5 sur 6 Do you ever have abnormal behaviors in your sleep? If yes, specify: Shouting Talking Walking (sleepwalking) Groaning/moaning Eating Hitting your partner in bed Other: These behaviors happen often: Do you have nightmares regularly? At the beginning of the night At the end of the night
NARCOLEPSY Have you ever felt unable to move for a few seconds at the moment when you are falling asleep or waking up, as if you were actually paralyzed? Never 1 to 10 times in my life more than 10 times in my life Have you ever felt a brief decrease in your muscle strength (or felt temporarily paralyzed) when experiencing an emotion such as joy, anger or surprise? Never 1 to 10 times in my life more than 10 times in my life I already fell to the ground in such a circumstance Have you ever seen imaginary objects, animals or people, or heard sounds or vices, at the moment when you were falling asleep (but while you were still awake)? Never 1 to 10 times in my life more than 10 times in my life ANY OTHER IMPORTANT INFORMATION? THANK YOU SOM-DOC-014 V9.0 Page 6 sur 6