Sleep History Questionnaire

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1 Sleep History Questionnaire Name Address Daytime Phone Height Evening Phone Weight Weight 5yrs ago Describe your sleep problem: 1. What time do you go to bed? 2. What time do you wake up? 3. What time do you get out of bed? 4. On the average how many hours of sleep do you get each night? 5. Do you allow yourself 8 hours of sleep per night? NO YES 6. Prior to bedtime, do you? A. Drink alcoholic beverages? NO YES B. Drink caffeinated drinks? NO YES (circle) coffee tea soda C. Do you take sleeping pills? NO YES

2 7. For the following questions below answer YES or NO: Do you have trouble going to sleep? Do you wake up frequently during the night? Do you wake up too early? Have you even been told you snore? Do you wake up gasping or feeling like you cannot breathe? Do you wake up with a headache? Has anyone told you that you stop breathing while sleeping? Do you wake up feeling tired, disoriented, or foggy? Do you toss and turn at night? Do you get nervous/restless feeling in your legs that is helped by walking or moving your legs? Do you get leg cramps or feel your legs tingling? Do you dream soon after lying down to sleep? Do you see things or hear things that are not there before falling asleep? Do you ever feel like you cannot move soon after lying down to sleep or just after you awaken? Do you ever feel weakness in your knees, neck, or arms when laughing, angry, sad, or emotional? Does your speech become slurred when you are tired? Does your jaw suddenly go slack when telling a joke so that your speech becomes slurred? Do you sleepwalk? Did you ever have very bad nightmares? Did you ever have a bed wetting problem? Do you talk in your sleep? Do you grind your teeth at night? Do you sleep with more than one pillow? Do you wake up to urinate during the night? Do you feel extremely drowsy during the day? Do you fall asleep at inappropriate times? Do you take naps during the day?

3 8. For the following list of medical conditions, check any that you have been diagnosed as having: emphysema or chronic bronchitis asthma neurologic or muscle disease, including: epilepsy, convulsions, stroke, Parkinson s disease, polio, infantile paralysis, meningitis amyotrophic lateral sclerosis, Lou Gehrig's disease, myasthenia gravis, paralysis or loss of sensation of any part of the body Thyroid disease Diabetes (sugar) Heart disease High blood pressure Tonsillitis, if yes, did you have a tonsillectomy? NO YES Any psychiatric disorders (depression, anxiety) 9. Please provide details for any illness you have checked or have that is not listed: 10. Have you gained or lost more than 10 lbs. in the last 15 years? NO YES If YES how much? 11. Have you sustained any serious head injuries? 12. Is there any history of sudden infant death syndrome in your family (SIDS)? NO YES

4 13. Have you had any serious accidents? 14. Have you had major operations? 15. Does anyone in your family (blood relative only) have a history of loud snoring, excessive sleepiness during the day, or sleep apnea: 16. Please list your medications (both prescription and non-prescription): Name of medication Amount taken How often taken Why are you taking it? 17. What is your occupation? 18. What hours do you work?

5 19. Have you ever smoked cigarettes? NO YES #of years Are you still smoking? 20. How much of the following caffeine-containing beverages do you drink on an average day: Coffee Tea Cocoa/chocolate drinks Soda/Cola 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. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose 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 If you score 10 or higher, please let your doctor know during your next visit. Situation Sitting and Reading Watching TV Sitting, inactive in a public place such as a theater or meeting As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score (add all responses): Chance of Dozing 3 Hospital Plaza Suite 407 Old Bridge, N.J Phone- (732) Fax- (732)

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