| Sleep Questionnaire pages 1-3 | |
|
SLEEP HISTORY These questions should be answered by you keeping in mind the following: a) Answer them in relation to the last 6 months, unless otherwise specified b) A “weekday” should be thought of as any day that you routinely work c) If you are engaged in shift work or have any type of unusual sleep/wake schedule, “day” and “night” should be interpreted as your major wake and sleep periods respectively. _________________________________________________ ________________________ NAME DATE My main sleep complaint involves (mark all that apply and describe): Please describe your sleep problem(s): ___________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ My sleep/wake problem began (date and details): ___________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ What have you done to treat your problem? _______________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ I hope the Sleep/Wake Disorder Center staff will help me by: _________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ SLEEP DISORDERS QUESTIONNAIRE Name __________________________________ DOB ____/____/_________ Weight ______ lbs Date ______________ Please rate your current (now or within the last week) symptoms (how you feel) by circling number 1 to 7 that most closely describes the degree or the frequency that you are bothered by a particular complaint or problem. 1 2 3 4 5 6 7 None or Very Slight Slight or Moderate or Major Great or Very Great Never or Rarely Seldom Occasionally or Often Very Often or Always 1) 1 2 3 4 5 6 7 How often do you fall asleep during the day when you are still or not busy? 2) 1 2 3 4 5 6 7 How often do you awaken feeling unrested even after adequate hours of sleep? 3) 1 2 3 4 5 6 7 How often do you suffer from unexplained fatigue or tiredness during the day? 4) 1 2 3 4 5 6 7 How often do you awaken feeling really sleepy or groggy? ===================================================================================================================== 5) 1 2 3 4 5 6 7 How great of a problem do you have with snoring? 6) 1 2 3 4 5 6 7 How often has a bed partner noted you stop breathing during sleep? 7) 1 2 3 4 5 6 7 How often is your sleep disturbed by other breathing problems? (Describe: _____________________________________________________________________) 8) 1 2 3 4 5 6 7 Do you suffer from headaches on awakening? 9) 1 2 3 4 5 6 7 How often do you awaken from heartburn or stomach acid in the mouth? =====================================================================================================================10) 1 2 3 4 5 6 7 How great of a problem do you have getting to sleep? 11) 1 2 3 4 5 6 7 How often do you wake up and have trouble falling back to sleep? 12) 1 2 3 4 5 6 7 How much do you toss and turn during your sleep? 13) 1 2 3 4 5 6 7 How often has a bed partner noted that your legs twitch or kick in you sleep? 14) 1 2 3 4 5 6 7 How often are you trouble by restless or “creepy” legs in the evening or night? =====================================================================================================================15) 1 2 3 4 5 6 7 How often do you feel completely paralyzed or “stuck” when just falling asleep or waking up? 16) 1 2 3 4 5 6 7 How often do you hallucinate people, voices, or sounds in the room when just falling asleep or when just awakening? 17) 1 2 3 4 5 6 7 How often during the day do you have episodes of sudden muscular weakness when laughing, angry, or in other emotional situations? =====================================================================================================================18) 1 2 3 4 5 6 7 How often do you have unusual behaviors in your sleep? (Circle type(s) of sleep behavior: walking, screaming out, nightmares, violence, eating, confusion, __________________________, __________________________). 19) 1 2 3 4 5 6 7 How much does your current sleep problem affect your family life? 20) 1 2 3 4 5 6 7 How much does your current sleep problem affect your work performance? 21) 1 2 3 4 5 6 7 How much does you current sleep problem affect you sense of well being? 22) 1 2 3 4 5 6 7 How often is your sleep disturbed by other problems? (Describe below). Comments: ________________________________________________________________________________________ Try to be specific with the following questions. Please rate your answer based on your average night. 23) What is your work schedule? Days: M T W Th F Sa Su 24) What time do you usually go to bed? __________ am / pm 25) What time do you usually arise for the day? __________ am / pm 26) How long does it usually take you to fall asleep after deciding to go to sleep? __________ minutes 27) How many times do you wake up during a typical night? __________ times 28) What are the total hours of sleep that you usually get a night? (Do not include the time you spend awake in bed at night). ____hours. ____minutes Name: ___________________________________________________ Date: _________________ MEDICAL HISTORY Height ______ inches Current Weight ________ lbs What is your maximum weight ever? __ __ __ __ lbs In the last 12 months, how many pounds have you (circle appropriate term) gained or lost? __________ Do you smoke tobacco?……………………… yes, currently no, quit no, never If yes, how much do you consume per day: cigarette packs/d other If quit, how long has it been since you stopped? years List the amounts of what you consume regularly (per day or week) Daily After Coffee, cups ________ ________ ________ Tea (cups/glasses) ________ ________ ________ Soft drinks (cans/drinks) ________ ________ ________ Beer, wine, liquor (cans/glasses/drinks) ________ ________ ________ Past and Current Health Problems Type of Problem/Treatment Date of Onset Physician or Facility Respiratory Conditions (asthma, COPD, etc.): _________________________ ____________ ____________________ Eyes, Ears, Nose, Throat/Mouth (glaucoma, Sinus, obstruction, allergies, surgery, etc.): _________________________ ____________ ____________________ Heart, Circulation, Blood Pressure: _________________________ ____________ ____________________ Head/Nervous System (e.g. head trauma, _________________________ ____________ ____________________ Convulsions, stroke): Psychological or Psychiatric Disorders: _________________________ ____________ ____________________ Stomach, Digestive, Intestinal Disorders: _________________________ ____________ ____________________ Kidney, Urological or Sexual Disorders: _________________________ ____________ ____________________ Arthritis, other musculoskeletal conditions, _________________________ ____________ ____________________ related chronic pain _________________________ ____________ ____________________ Metabolic/Hormonal Disorders, (diabetes, thyroid, etc.) _________________________ ____________ ____________________ Surgical Operations, (e.g. tonsillectomy, nasal surgery, hysterectomy, etc.): _________________________ ____________ ____________________ _________________________ ____________ ____________________ _________________________ ____________ ____________________ _________________________ ____________ ____________________ |
|
|
||||||||||||||
|
||||||||||||||
