Sleep History and Questionnaire
Patient Name ______________________________________Date of Birth: ________________
Male
Married
Female
Single
Height: ______ Weight: ________ Neck Size: _______ BMI: _______
Divorced
What is your Current Occupation? _________________________________ How long? ______
Please list all Previous Occupations ________________________________________________
Who referred you for this Sleep Study? _____________________________________________
Who is your Primary Care Physician? _______________________________________________
Please list all your current medications and supplements with dosage:
____________________________________________
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SLEEP HISTORY
Have you ever had a sleep study before?
Yes
No
If yes, where was your last study done? _____________________________ When was it done? __________
Have you ever been diagnosed with Sleep Apnea?
Yes
No
Are you currently being treated for Sleep Apnea?
Yes
No
What type of treatment are you using?
CPAP
Auto PAP
BiPAP
BiPAP ST
ASV
I was, but not using it now
Oral Appliance
What is your current pressure? __________How long have you had your machine? _________
Where do you currently get your supplies? __________________________________________
1
SLEEP PROBLEMS
Please check all that apply at the time of this appointment:
Snoring
Tired or sleepy during the day
Difficulty falling asleep
Gasping, choking, or pauses in breathing while asleep
Difficulty staying asleep
Other______________________________________
Morning Headaches
AWAKE
How do you feel when you wake up in the morning?
Tired (I want to continue sleeping)
Suffer from pains or stiffness
Unpleasantly dry mouth
As a result of sleepiness, have you ever experienced any of the following?
Auto Accident
Reduction in quality of life
Poor Work Performance
Work-related injury
None of these
RESTLESS LEG
Do you have a strong urge to move your legs while sitting or lying down?
Yes
No
Is the sensation worse when sitting/lying down than when moving around?
Yes
No
Does this sensation improve if you get up, stretch your legs, or walk around?
Yes
No
Is this sensation worse in the evening or night than in the morning or afternoon?
Yes
No
Does this occur more than once a week?
Yes
No
Yes
No
(If you answered No - go to next section of question)
If yes, how many times per week? __________________________
Does this sensation interfere with your sleep?
If yes, how often? ________________________________________
2
EXCESSIVE SLEEPINESS
Do you feel more tired during the day than you think is normal?
Yes
No
Do you awaken frequently during the night for no obvious reason?
Yes
No
Have you ever been paralyzed (unable to move all of your muscles) for
a short time when you first awaken or are falling asleep?
Yes
No
Have you ever seen something in the room with you as you awaken or
as you are falling asleep which disappears within a minute or two?
Yes
No
When you are laughing, surprised, or angry do your muscles become weak
(jaw dropping, leg buckling, or falling down)?
Yes
No
Yes
No
Do you have any unusual sleep behaviors like sleep walking, talking in your
sleep, or acting out your dreams?
Describe _____________________________________________________
SLEEP HABITS
Please answer the following questions for work days and non-work days
Work Days
Non-work Days
What time do you go to bed?
_______ am/ pm
______ am / pm
What time do you actually fall asleep?
_______ am/ pm
______ am / pm
What time do you get out of bed?
_______ am/ pm
______ am / pm
How many hours do you spend in bed?
_______ hours
______ hours
How many hours do you think you actually sleep? _______ hours
______ hours
How many times a night do you awaken?
______ times
_______ times
What or why do you think you wake up at night? _________________________________
How long before you are able to return to sleep? _________________________________
How many days per week do you nap and for how long?_____________________________
3
GENERAL HABITS
Please choose which of the following describes your normal work schedule:
Day Shift (what hours do you work? __________________________)
Evening /Afternoon shift (3:00 to 11:00)
Night shift (11:00 to 7:00)
Variable schedule (Please explain _____________________________________________)
Retired
Unemployed
Stay at home parent
Please answer the following questions:
How many cups of caffeinated beverages (coffee, tea, soda, etc.) do you drink a day? ______
What time do you usually drink your last caffeinated beverage each day? ________________
Do you smoke?
How many packs per day? ____________
Yes
No
Have you ever smoked?
How long ago did you quit? ___________
Yes
No
Do you consume alcoholic beverages?
Yes
How often? Daily
Weekly
Social drinker
No
Do you have a history of Drug use?
No
Yes
How many times a week do you exercise for 30 minutes or more? ______________________
4
MEDICAL HISTORY
Have you ever been diagnosed with any of the following? (Please check all that apply)
Allergies / Nasal Congestion
Sinusitis
Seizures / Epilepsy
Asthma
Down Syndrome
Depression
Emphysema / COPD
High cholesterol
Anxiety
Congestive Heart Failure (CHF)
Diabetes
Panic Disorder
Heart Valve Problems
Migraine Headaches
Schizophrenia
Heart disease (Heart Attack)
Kidney Disease
Liver Disease
High Blood Pressure / Hypertension
Brain Injury
Swallowing problems
Irregular heart beat
Atrial fibrillation
Narcolepsy
Hypothyroidism (low thyroid)
Fibromyalgia
OSA
Obesity
Does anyone in your family have a history of any of the following? (Check all that apply)
Obstructive Sleep Apnea (OSA)
Narcolepsy
Excessive Sleepiness
Restless Leg Syndrome
Other Sleep Disorders
Sudden Death
Alzheimer’s
Coronary Heart Disease
Please list any surgeries you have had and when:
Type of surgery:
Date of Surgery:
Type of surgery:
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5
Date of Surgery:
EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the situation described below, in contrast to just
feeling tired? Use the following scale to choose the most appropriate number for each
situation:
0123-
Would never doze
Slight chance of dozing
Moderate chance of dozing
High chance of dozing
Situation
0-3
Sitting and reading
Watching TV
Sitting, inactive, in a public place
Passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting an talking to someone
Sitting quietly after lunch with no alcohol
In a car, while stopped for a few minutes in traffic
Total:
6