Date: ______________
Sleep Disorders Center Pre-Testing Questionnaire
Name : __________________________
Birthdate: __________
Years of Education: _______
__________________________________________________________________________________________
1. Briefly describe your sleep problem: _____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. How long have you had this problem? ____________________________________________________
3. What time do you usually try to go to sleep? _____ A.M/P.M Earliest time: _____ Latest Time: ______
4. On the average, how long does it take you to fall asleep? ___________________________
5. How many days a week does it take you more than 30 minutes to fall asleep? _____________
More than 60 minutes to fall asleep? ____________
6. When falling asleep or trying to fall asleep, how often do you: (Check one box for each statement)
Never Sometimes Often
a. Have thoughts racing through your mind?
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b. Feel sad or depressed?
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c. Have anxiety (worry about things)?
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d. Feel muscular tension?
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e. Feel afraid of not being able to sleep?
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f. Feel unable to move?
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g. Have creeping, crawling or aching feelings in
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Your legs (feel like you have to move them)?
h. Have vivid, dream-like scenes even though you
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Know you are not totally asleep?
i. Have any kind of pain or discomfort?
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j. Feel afraid of the dark or anything else?
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7. About how many hours of actual sleep do you get each night _____hours _____minutes
8. How many times do you usually awaken at night? ___________________________________
9. If you awaken during the night, is it usually during the:
______ First half of the sleep period? ______ Second half of the sleep period?
10. How often do you (check one box for each statement):
Never Sometimes Often
a. Feel afraid you won’t return to sleep after awakening?
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b. Sleep with someone in your bed?
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c. Sleep with someone else in your room?
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d. Have restless, disturbed sleep?
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e. Get out of bed at night?
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f. Snore loudly?
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g. Feel your heart pounding during the night?
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Never
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Sometimes
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Often
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h. Sweat a lot during the night?
i. Walk in your sleep?
j. Fall out of bed at night?
k. Wake up at night screaming, violent or confused?
l. Have abnormal movements while asleep?
m. Wet the bed?
11. My sleep is frequently disturbed by (check all that are true)
☐ Heat/cold
☐ Hunger/thirst
☐ Light
☐ Need to urinate
☐ Asthma
☐ Cough
☐ Choking
☐ Frightening dreams
☐ Chest pain
☐ Noise or movement of bed partner
☐ Shortness of breath
☐ Indigestion, gas, heartburn
☐ Creeping, crawling, or aching in legs
12. What time do you usually get up in the morning? ________ A.M/P.M
13. What is the earliest time you get up? ________ A.M/P/M
14. What is the latest time you get up? ________ A.M/P/M
15. How many naps do you take in a usual week? _______________________________
a. How long are you usually asleep during a nap? ________ hours _______ minutes
b. Are the naps refreshing? ______Yes ______ No
16. How many times a week do you fall asleep unintentionally during the day? _____________________
17. How often do you (check one box for each statement):
Never Sometimes Often
a. Depend on an alarm to wake up?
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b. “Sleep in” in the morning (more than one hour past
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your usual wake-up time)
c. Have a very hard time waking up?
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d. Feel unable to move when waking up?
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e. Have dream-like images when waking up even
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though you know you are not asleep?
f. Wake up confused or disoriented?
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g. Wake up with a headache?
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h. Wake up nauseous (sick to your stomach)?
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18. How often do you (check one box for each statement):
Never Sometimes Often
a. Feel tired during the day?
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b. Feel sleepy during the day?
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c. Fall asleep unintentionally?
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d. Feel sad or depressed?
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e. Have anxiety (worry about things)?
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f. Feel muscular tension?
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g. Have thoughts racing through your mind?
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h. Weakness in your muscles when laughing, surprised, angry or excited? ☐
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19. How much of the following do you drink?
Regular Coffee ______ cups per day (caffeinated)
Beer ______ cans per week
Tea
______ cups per day
Wine ______ glasses per week
Soda
______ cans per day
other alcoholic ______ drinks per week
20. What beverages do you usually drink within two hours of going to bed?
_________________________________________________________________________________
21. Do you smoke? _____ Yes _____ No ______ Cigarettes _____ Cigars _____ Pipe
How much per a 24 hour period? _____________________________________________________
How long have you been smoking? _______________________ Years
22. Please list any sleeping pill taken in the past: ______________________________________________
__________________________________________________________________________________
23. Current Medications or attach list:
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
_________________________ _________________________ _________________________
24. How many times each week do you participate in a sport or partake in some other form of exercise?
__________________________________________________________________________________
25. Do any of your relatives have a sleep problem? If so, please describe. _________________________
_________________________________________________________________________________
_________________________________________________________________________________
26. What are your usual work hours? Work starts at: _______ A.M/P.M. and ends at ______ A.M/P.M?
27. What is your personal interpretation as to why you have your particular sleep/wake problem?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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28. Have you ever had a sleep study ______ Yes ______ No ______ Year
a. If yes City, State and Sleep Center Name? ___________________________________________
_____________________________________________________________________________
29. Have you ever been prescribed a Cpap or Bipap Machine? ______ Yes ______ No
Rev. 10/28/2014