Sleep Health Questionnaire

Sleep Health Questionnaire

Patient:                               Date:

Please describe your sleep problem(s) and how long this has been a problem: 

Symptoms that apply to you:


Medical History:


   Other Not Listed:  


YR              Operation(s)                                                                                                                                                  

Hospitalization(s) in past 12 months:

YR               Reason


Allergies: (medication/food/etc…) 

Family History: Please list any major health problem(s), if deceased list the age of occurrence and cause of death:





Personal History:

  1.  Do you Smoke: , How Long: yrs, Pack(s) per Wk:   

  2. Former Smoker: How Long: yrs, Pack(s) per Wk:  

  3. Alcohol consumption:


  4. Caffeine daily consumption: Cups Coffee, Cups Tea, Cups Soda, Cups Energy Beverage

Patient Label

Sleep History: Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Use the following scale to circle 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

                                Situation                                                                                               Chance of dozing

While sitting and reading



While watching TV


While sitting inactive in a public place


As a passenger in a car for an hour without a break


While lying down to rest in the afternoon when


While sitting and talking with someone


While sitting quietly after lunch without alcohol


While in a car stopped for a few minutes in traffic


Check what best describes your overall sleepiness

  1. How many times a night do you typically awaken?      Epworth Total Score out of 24

  2. Hours per night you sleep on average?     Mon-Thurs sleep time     Wake time

  3. Do you take naps? If Yes, how long in minutes     Fri-Sun sleep time     Wake time

  4. Do you or have you  ever experienced episodes of muscle weakness, loss of muscle strength, or limp muscles in any part of your body during the following activities?

          When you laugh:
          When you are angry:
          When hearing or telling a joke:
          When tense or under stress:
          During exercise:
          Other: If yes specify:

    5. Are your dreams so real that you cannot tell if you are awake or asleep?

    6. On occasion do you awaken soon after going to sleep or in the morning feeling paralyzed, unable to move or talk, which lasts only for a few seconds or minutes?

    7. Have you ever suffered a head injury, meningitis, encephalitis, stroke or seizures?

    8. Do you sleep better away from home?

    9. Do you relate your sleep problems to a specific change or stress in your life?

   10. If awakened do you feel it necessary to eat or drink in order to resume sleep?

   11. Do you use prescription or over the counter medicines to help you sleep?

Patient Label

   12. Do you typically have sleepiness associated with periods, PMS, or menopause?

   13. Do you experience repetitive arm or leg movements while asleep?

   14. Do you have leg and/or arm discomfort when going to bed or when sitting still, which goes away by moving or walking? (Answer No, if your discomfort is muscle cramping)

   15. Do you talk in your sleep?

   16. Do you grind or clench your teeth while you sleep?

   17. Do you sleep walk?

   18. Do you have episodes of extreme terror / screaming during sleep, yet have little if any recall of the event?

   19. While asleep, have you ever acted out a dream or injured yourself or bed partner?

   20. Do you have episodes of bed-wetting during sleep? (More than once a month)

   21. Do you cough at night?

   22. Do you work at night or change shifts?

If Yes, please Describe:  

------------------------------------------------------------------FOR OFFICE USE ONLY---------------------------------------------------------------

Physical Exam: (To be complete by Nurse or Technologist)    

Ht: Inches     Wt: Lbs     BMI:      HR:      BP: /      BPM:


Neck Circumference: Inches                Mallampati Classification




Physician:               Date:

Leave this empty:

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Document name: Sleep Health Questionnaire
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January 25, 2021 8:42 am CDTSleep Health Questionnaire Uploaded by Dylan Richardson - IP