Sleep Disorders Center St. Michael s Dr fax Santa Fe, New Mexico QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN:

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1 Sleep Disorders Center St. Michael s Dr fax Santa Fe, New Mexico QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: Do you now have or have you had: Hypertension (high blood pressure) Yes No Sinus problems Yes No Allergies Yes No Heart problems Yes No Stroke Yes No Tonsillectomy Yes No Nasal fracture or surgery Yes No PLEASE EXPLAIN ANY YES ANSWERS: OTHER MEDICAL PROBLEMS AND/OR SURGERIES: DATE: HEIGHT: WEIGHT: CURRENT MEDICATIONS: 1

2 Please answer the following questions on a scale of 0 to 4 (0: not at all; 4: very great) 1. How great a problem do you have with sleepiness (feeling sleepy, struggling to stay awake during the daytime)? How great a problem do you have with fatigue (tiredness exhaustion, lethargy even when you are not sleepy)? Do you snore? Do you hold your breath or stop breathing while asleep? Do you have gas, indigestion or heartburn at night? Do you have night sweats? Do you have frequent headaches in the morning? Number of times you wake up to urinate? Do you have difficulty breathing while lying flat? Do you have shortness of breath with exertion? Do you choke while eating? When you awaken from sleep do you ever feel paralyzed, unable to move even though you are awake? When someone startles you or makes you laugh do you get weak, fall or do your knees buckle? When falling asleep do you have vivid dreams or hallucinations? Do you have frequent uncontrollable bouts of sleep or an irresistible urge to sleep? Do you have problems breathing through your nose? Are you a mouth breather? Do you wake up with a dry mouth? Do you wake up gasping or short of breath?

3 Sleep Disorders Center St. Michael s Dr fax Santa Fe, New Mexico Do you have problems with memory or concentration? Do you have problems with libido or impotence? Are you irritable? Do you feel depressed? Do you feel anxious? Have you had motor vehicle accidents caused by sleepiness? Do you fight sleep while driving? Do you grind your teeth? Do your ankles swell? SLEEP HISTORY: Usual bedtime Usual length of time to fall asleep Usual wake-up time Average total sleep time Average number of awakenings Average length of awakenings Do you nap during the day? Yes No If yes, number of naps Length of naps Are naps refreshing? Yes No Do your legs kick or twitch frequently during the night? Yes No 3

4 Do you have symptoms of restless legs (crawling or aching feeling and inability to keep your legs still)? Yes No Do you feel refreshed or restored in the morning? Yes No How long does it take you to "get going"? Weekends or days off: Usual bedtime Usual wake up time Total sleep time Describe your sleep environment: Watch TV Yes No Bed partner Yes No Animals in room Yes No Room temperature Other SOCIAL HISTORY: What is your present occupation? What are your work hours? Have you ever smoked? Yes No If yes, how many years? Average number of packs/day? Have you quit smoking? Yes No When? 4

5 Sleep Disorders Center St. Michael s Dr fax Santa Fe, New Mexico Do you drink alcoholic beverages? Yes No If yes, what is your consumption? Light Moderate Heavy Do you drink caffeinated beverages? Yes No How many per day? Do you exercise? Yes No How often per week? Do you have any unusual eating habits? Yes No FAMILY HISTORY: Please explain Marital status: single married divorced separated widowed Children Number ages health problems Mother living? Yes No Age Medical problems/cause of death: Father living? Yes No Age Medical problems/cause of death: Brothers? Ages Health problems Sisters? Health problems Ages Do any members of you family have sleep problems: If so, please describe: 5

6 EPWORTH SLEEPINESS SCALE How likely are you to doze or fall asleep in the following situations, in contrast to feeling just 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 imagine how they would affect you. Use the following scale to choose the most appropriate number in 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 Sitting and reading Watching TV Sitting, inactive in a public place (i.e.: theater, meeting) As a passenger in a car for an hour without a break Lying down for a rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Now that you have finished the questionnaire, do you have any other comments you would like to add? 6

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