Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services. Pa ent Iden fica on: Pa ent name: Date: Age: Date of birth: Who is filling out this ques onnaire? Please list the name of your primary care physician: Please list the names of physician(s) or friends who referred you to the EvergreenHealth Sleep Services: Main Symptom Associated with Sleep: Please list the reasons or symptoms that led you to the EvergreenHealth Sleep Services: When did this begin? Do you have these addi onal symptoms? Snore Stop breathing in your sleep E xcessive sleepiness in the day me. Restlessness or discomfort in your legs in the evenings. Kick or twitch your legs repeatedly in sleep. Sleepwalk. Night terror. Unusual movement in sleep. Sleep Schedule: On Weekdays What me do you go to bed? How long does it take you to get to sleep? What me do you get up? Do you use an alarm? Yes No How many hours of sleep do you usually get? On Weekends or days you are not working/going to school? What me do you go to bed? How long does it take you to get to sleep? What me do you get up? Do you use an alar m? Yes No How many hours of sleep do you usually get? Page 1 of 6
Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situa ons? Use the following scale to choose the most appropriate number for each situa on. 0 = Never doze. 1 = Slight chance of dozing. 2 = Moderate chance of dozing. 3 = High chance of dozing Situa on Chance of dozing Si ng and reading 0 1 2 3 Watching TV 0 1 2 3 Si ng, inac ve in a public place, e.g., theater or mee ng 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down to rest in the a ernoon when circumstances permit 0 1 2 3 Si ng and talking to someone 0 1 2 3 Si ng quietly a er lunch without alcohol 0 1 2 3 In a car while stopped for a few minutes in traffic 0 1 2 3 Review of systems: Please check all boxes reflec ng your symptoms System Symptom Yes No 1. Cons tu onal: Do you have fa gue, sleepiness, or a problem with concentra on or memory? Have you had a weight change in the past 5 years? 2. Eyes: Do you wake up with red, watery, or painful eyes? 3. Ears, Nose, Throat, Mouth: 4. Allergy/Immunologic system: Do you wake up with a dry mouth or sore throat? Do you grind your teeth and/or wear a night guard? Are you a mouth breather? Do you wake up with sneezing or watery eyes? 5. Respiratory system: Do you wake up at night with shortness of breath or wheezing? Do you wake up gasping or coughing? 6. Cardiovascular system: Do you wake up with chest pain or angina? Do you wake up with heart palpita ons? Do you have swollen ankles or limbs? 7. Musculoskeletal system: Do you wake up with joint pain, s ffness, or swelling? Do you wake up with muscle pains or cramps? Page 2 of 6
Yes No 8. Gastrointes nal System: Do you wake up with reflux or heartburn? 9. Genitourinary System: Do you wake up to urinate frequently? Do you wet your bed? 10. Neurologic Syste m: Do you wake up with a headache? Do you have unusual seizure in your sleep? Do you wake up with total body paralysis? Do you experience hallucina ons upon falling asleep or waking up? Do you experience muscle paralysis or weakness with laughter, anger or emo onal outbursts? 11. Psychiatric system: Do you feel depressed? Do you have anxiety or panic a acks? 12. Endocrine system: Do you feel excessively war m or sweaty? Do you feel excessively cold? Do you feel unusually thirsty? Are you or could you be pregnant? Page 3 of 6
Past Medical History: 1 Did you have previous diagnosis of Sleep Apnea? YES NO If you have previous diagnosis of Sleep Apnea, when was it diagnosed? If you have previous diagnosis of Sleep Apnea, where was it diagnosed? 2 Did you have previous diagnosis of Restless Leg Syndrome? YES NO 3 Did you have previous diagnosis of Narcolepsy? YES NO 4 Did you have previous diagnosis of inso mnia? YES NO 5 Do you have A en on Deficit Hyperac vity Disorder? YES NO Please list other medical conditions here: 6 7 8 9 10 11 12 13 14 Cancer, If yes, what form? YES NO Stroke YES NO Diabetes YES NO High Cholesterol YES NO COPD / Asthma YES NO Depression YES NO Anxiety YES NO Neuropathy YES NO Chronic Pain YES NO OTHER: Past Surgical History: 1 Have you had previous surgery for snoring or sleep apnea: YES NO 2 Have you had tonsillectomy: YES NO 3 Have you had nasal surgery: YES NO 4 Have you had tracheostomy: YES NO 5 Have you had palatal expansion procedures? YES NO 6 Have you had orthodon c procedures on your jaw? YES NO Page 4 of 6
Personal/Social history: What is the nature of your work? When do you work? Please mark all that apply. Day Evening Night Work at home R etired Student (what grade level? ) Are you married? Yes No Are you sharing a room with another person? Yes No Do you have children? Yes No Do you have pets in your bedroom? Yes No What is your height? What is your weight? Habits How much alcohol do you drink in 1 week? Beers ; Glasses of wine ; Shots ; How many cups of caffeinated beverages do you drink in 1 day? Coffee ; Shots of espresso, or cans of caffeinated soda?. Have you ever smoked? Yes No. If you quit smoking, when did you last smoke? If yes, how many packs do you smoke in 1 day? Family History: Please check if any close rela ves have had any of the following diseases. Please indicate rela ve: Brother/sister, mother/father, Yes No grandparent, maternal/paternal aunt/uncle Sleep apnea Restless Leg Syndrome Narcolepsy Sleep walking Parkinson s Disease Insomnia Mental or emo onal problems High blood pressure Heart disease Stroke Diabetes Asthma Page 5 of 6
Please list curre nt medications: (include over the counter, vitamins, herbal) Name of Medica on Dose (mg) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Frequency: #/day Year started Please List All Medica on Allergies: Approved 08/10 Page 6 of 6