ManagedbyGLOBALSLEEP,YourHospitalPartnerinSleep

Phone:(888)2256167Fax:(877)8094922

SLEEPSTUDYQUESTIONNAIRE
PATIENTNAME:

Thefollowinginformationwillhelpusobtainabetterunderstandingofyoursleepandwakebehavior.Pleaseanswerallquestions
tothebestofyourability.Ifpossible,pleasefilloutthequestionnairewiththeassistanceofsomeonefamiliarwithyour
sleep/wakehabits.Allinformationisconsideredconfidential.

Whatisyourmainsleepcomplaint&how

longhasthisbeenaproblem?

MedicationsPrescriptionandOverthecounter:(mayattachseparatelisting)
MedicationName
Frequency

GeneralHistory:

PLEASEPRINT
Dosage

Yourweight?

Yourheight?

Doyouusetobaccoproducts?
Doyoudrinkmorethantwoalcoholicbeveragesperday?
Doyoudrinkmorethantwocaffeinatedbeveragesperday?
Haveyouhadanyrecentproblemswithyourmemoryorconcentration?
Haveyouhadanychangesinyoumoodorbeenmoreirritablelately?
Areyouhavinganyotherproblems(e.g.,stress,relationshipsissuesetc.)?
Haveyoubeendepressedlately?
Areyouhavinganysexualproblems(erectiledysfunction,lackofdesireetc.)?
Doyouworkshiftsortravelacrosstimezonesfrequently?

Doyoufallasleeporbecomesleepywhen:
Driving?
Atwork?
Doyoutakeintentionalnaps?
Doyouexperienceshortperiodsofmuscleweaknessorlossofmusclecontrol(especiallywith
laughterorexcitement)?
Doyouexperiencevividdreamlikeepisodeswhenfallingasleep?
Doyoufeelunabletomove(paralyzed)brieflywhenfallingasleep?
Doyoueverexperienceanuncomfortableorrestlesssensationinyourlegswhenyourelaxor
arefirstgoingtosleepthatisrelievedbymovingorgettingoutofbedandwalking?
Whileasleepdoyou:
Snoreorbeentoldyousnore?
Holdyourbreath?Orhaveyoubeentoldyoustopbreathingwhileasleep?
Suddenlyawakenchokingorgaspingforbreath?
Wakeupwithadrymouth?
Walkortalkinyoursleep?
Moveaboutorengageinaggressivebehaviorswhileasleeporwakingupfromadream?
Havelegorarmjerks,twitchesorkicks?
Havenightmares?
Wakeupwithaheadache?
Tossandturnorhaverestlesssleep?
Awakenatnightwithheartburnoranacidtasteinyourmouth?

YES
YES
YES
YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO
NO
NO
NO

YES
YES
YES
YES

NO
NO
NO
NO

YES
YES
YES

NO
NO
NO

YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

SLEEP STUDY QUESTIONNAIRE

(Page2)

Whentryingtogotosleepdoyou:
Thinkyouneedasleepingpill,eitherprescriptiondrugoroverthecountersleepingaidin
ordertofallasleep?
Consumewine/beeroranotheralcoholicbeverageinordertofallasleep?
Takesleepingpillsornonprescriptionsleepingaidsonnightlybasisformorethanthree
weeks?
Layinbedformorethanthirty(30)minutesunabletogotosleeporreturntosleep?
Dreadgettingintobedbecauseyouthinkyouwill"never"fallasleep?
Doyousleepbetterawayfromhome?
Yournightroutineorsleephabits:
Whattimedoyougotobedonworkdays?

Whattimedoyougotobedonnonworkdays?

Ontheaveragehowlongdoesittakeyoutofallasleep?

Howoftendoyouawakenatnight?

Howlongdoyoustayawake?

Whattimedoyougetuponworkdays?

Whattimedoyougetuponnonworkdays?

Howmanytotalhoursofsleepdoyougetinatypicalnight?

Whendoyoufunctionbestduringtheday? Morning Afternoon

YES

NO

YES
YES

NO
NO

YES
YES
YES

NO
NO
NO

Evening

MedicalHistory:

HighBloodPressure

SinusProblems

Diabetes

Arthritis(chronicstiffness/pain)

FibromyalgiaSyndrome

ThyroidProblems

Anemia

HeartDiseaseorAngina

LungDisease

ElevatedCholesterol
Stroke

CurrentlyExperiencing:
Heartburn(GEreflux)
AIDS/HIV
Cancer
Meningitis
Frequentnighttimeurination
Hepatitis
Depression/Anxiety
Tuberculosis
LiverDisease
Malaria
SeizuresorEpilepsy
Strep
FrequentHeadaches
Flu
PriorhistoryofSleepApnea
MRSA
PriorhistoryofRestlessLegs
Lice
Obesity
Staph(resistantto
medication)

TheEpworthSleepinessScale:
0Wouldneverdoze1slightchanceofdozing2moderatechanceofdozing3highchanceofdozing
Sittingandreading
WatchingTV
Sitting,inactiveinpublicplace(e.g.atheaterorameeting)
Asapassengerinacarforanhourwithoutabreak
Lyingdowntorestintheafternoonwhencircumstancespermit
Sittingandtalkingtosomeone
Sittingquietlyafteralunchwithoutalcohol
Inacar,whilestoppedforafewminutesintraffic

0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3