Sleep Questionnaire

The following questions will help us to understand your sleep disorder and to determine the proper treatment. Please answer them to the best of your ability. Required fields are marked as "*required". If you wish to only complete the scoring portion of this questionnaire, you will still be required to provide your name, email address and phone number so we can contact you.

Name *required Date (mm/dd/yy)
Email address *required
Phone (home) * (work) Physician
Address
Insurance Company Policy Holder
ID or Policy Number Group Number
Male Female Date of Birth (mm/dd/yy)
Height feet in. Weight lbs Neck size in.

How likely are you to doze in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they may have affected you. If you have a bed partner, have them go through the questions with you. Use 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

Section 1:
0   1   2   3    
      1. Sitting and reading.
      2. Watching TV.
      3. Sitting inactive in a public place (theater, meeting, etc.) .
      4. Lying down to rest in the afternoon when circumstances allow.
      5. Sitting and talking to someone.
      6. Sitting quietly after lunch.
      7. In a car, while stopped in traffic for a few minutes.
               

Section 2:
1. Sleep Problem
Please describe the problem(s) you are having with your sleep.
2. General Information
What time do you go to bed?
When do you wake up in the morning?
Is your sleep unsatisfactory? Yes No
Do you wake up with a headache? Yes No
Do you have insomnia? Yes No
3. Night Time Symptoms
Do you snore loudly at night? Yes No
Do you stop breathing in your sleep or wake up choking? Yes No
Do your legs jerk when you sleep? Yes No
Do you wake up with a sour taste in your mouth? Yes No
Do you have vivid dreams or nightmares? Yes No
4. Daytime Symptoms
Are you drowsy during the day? Yes No
Does daytime sleepiness interfere with your work? Yes No
Have you fallen asleep while driving or eating? Yes No
Do you nap during the day? Yes No
Do you ever fall or lose muscle strength when laughing, angry or emotionally upset? Yes No
5. Habits and Medications
Do you smoke? Yes No   How much? Packs Per Day?
Do you drink alcohol? Yes No   How much? Drinks Per Day?
Do you drink coffee, teas or soda? Yes No
Medications and drugs taken? (please list)
6. Chronological
Do you have irregular work hours? Yes No
If so what are they?
Is your bedtime irregular? Yes No
7. Past History
Any previous sleep problems? Yes No
How long have you had a sleep problem?
Recent weight gain? Yes No
Sleep problem as a child? Yes No
Other health problems you currently have, or had in the past?
8.

Review of Symptoms
Do you have any of the following? Check box if it applies to you.

  high blood pressure
  heart condition
  asthma / emphysema / bronchitis
  nasal obstruction / congestion / sinus / allergy
  chest pains
  heart burn at night
  leg cramps / pins and needles in legs
  thyroid problem
  diabetes
  low blood sugar
  depression