Pre/Post Sleep Questionnaire


St. Vincent’s Sleep Disorder’s Center

Pre-Sleep Questionnaire

 

Name:      Date:      File#:  

 

Height: Weight:  

 

  1. Did you have any Naps today?  

If Yes, what time/how long?   1    2   3   4

  1. Have you taken any PRESCRIBED MEDICAITONS today?

If so, what?  

  1. Have you taken any MEDICATIONS this past week?

If so, what?    When?    How much?

  1. Have you taken any NON-PRESCRIBED MEDICATIONS today?

If so, what?    When?    How much?

  1. Have you had any ALCOHOLIC BEVERAGES today?

If so, what?    When?    How much?

  1. Have you FELT ILL today or do you feel ill now?

If yes, how and when?

  1. Did anything OUT OF THE ORDINARY happen today?

If yes, what?

  1. Did you feel SLEEPY today?
  2. Did you have a PHYSCIALLY STRENUOUS day?
  3. When did you EAT your last meal?

Compared to usual, was it?  

  1. How SLEEPY do you feel right now?

         

 

Please sign off on any physicians that would like a copy of this study.

                                    -Please include phone numbers-

 

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Patient Signature:

 

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St. Vincent’s Sleep Disorder’s Center

Post-Sleep Questionnaire

 

Name:

Date:

 

  1. Did you take any medication last night?

Meds/time      1.            2.

                        3.             4.

  1. How long did it take you to fall asleep last night? Hr/Min

      Compared to usual, was this

  1. Did you have difficulty falling asleep last night?

      Reason:

  1. Did you wake up during the night?

      If so, how many times?

  1. Did you have difficulty falling back asleep?

      Why?

  1. How long did you sleep last night? Hr/Min
  2. Did you dream last night?

      If so, were your dreams

  1. How DEEPLY do you feel you slept last night?

         

  1. How did you FEEL upon awakening?

         

  1. How would you evaluate the REFRESHING QUALITY of your sleep last night?

         

  1. How TIRED do you feel right now?

         

  1. How SLEEPY do you feel right now?

         

  1. How ALERT do you feel right now?

         

 

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Document name: Pre/Post Sleep Questionnaire
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