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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:

Loud Snoring Choking/Gasping During Sleep Excessive Daytime Sleepiness Morning Headaches Stop Breathing During Sleep (Witnessed Apnea) Nasal Obstruction/Congestion Wake w/ Dry Mouth Difficulty Initiating or Maintaining Sleep Wake Feeling Un-Refreshed Suffered an Accident/Injury Due to Falling Asleep

Medical History:

Cardiovascular Disease Stroke Hypertension CHF COPD Neuromuscular Disorders Diabetes Anxiety Depression Impaired Cognition Asthma Chronic Bronchitis Sleep Apnea Narcolepsy Restless Legs

Other Not Listed:

Operations:

YR Operation(s)

Hospitalization(s) in past 12 months:

YR Reason

Medication(s):

Allergies: (medication/food/etc…)

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

Father:

Mother:

Sister:

Brother:

Personal History:

Do you Smoke: , How Long: yrs, Pack(s) per Wk:
Former Smoker: How Long: yrs, Pack(s) per Wk:
Alcohol consumption: Never Rarely Weekend's Only < 2oz liquor/beer/wine per Day > 2oz per Day
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

None

Mild

Moderate

Severe

How many times a night do you typically awaken? Epworth Total Score out of 24
Hours per night you sleep on average? Mon-Thurs sleep time Wake time
Do you take naps? If Yes, how long in minutes Fri-Sun sleep time Wake time
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:

Nose: Normal Septal Deviation Obstruction Other:

Neck Circumference: Inches Mallampati Classification

Class I: Soft Palate, Fauces, Uvula, Pillars

Class II: Soft Palate, Fauces, Portion of Uvula

Class III: Soft Palate, Base of Uvula

Class IV: Hard Palate Only

Oropharynx: Normal Enlarged Tongue Long Uvula Short AP Diameter Retrognathia

Physician: Date:

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

January 25, 2021 8:42 am CDT

Sleep Health Questionnaire Uploaded by Dylan Richardson - dylan@danmarkcom.com IP 12.233.60.59