Page 1 of 8. SLEEP DISORDERS CENTER QUESTIONNAIRE Swedish Medical Center. Name: Date: Height: Weight: Neck Size: Handedness: Right/Left.

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1 Page 1 of 8 SLEEP DISORDERS CENTER QUESTIONNAIRE Swedish Medical Center Name: Date: Date of Birth: Age: Sex: M F Height: Weight: Neck Size: Handedness: Right/Left Which physician evaluated you for your sleep problem? Name: Address: Phone #: Who is your Primary Care Physician? Same as above? Yes No If No fill in Primary Physician Below Name: Address: Phone #: PLEASE ANSWER THIS QUESTIONNAIRE WITH THE ASSISTANCE OF YOUR BED PARTNER CIRCLE ANSWERS OR FILL IN THE BLANKS AS INDICATED If you have filled out this same questionnaire for the Colorado Sleep Disorders Center at Swedish Medical Center within the last 6 months you may stop here

2 Page 2 of 8 1. What is your sleep problem? 2. What tests have been done for your sleep problem? 3. What have other doctors tried to help your sleep problem? 4. What have you tried for your sleep problem?

3 Page 3 of 8 1. List your current tobacco use (if none, write none): 2. List your alcohol use (if none, write none ): 3. List your caffeine use (if none, write none ): 4. Do you use oxygen? Yes No 5. Do you use CPAP or BiPAP? Yes No 6. If you use oxygen or CPAP or BiPAP list how much you use or the dose and when you use it (day, night, all the time, etc.): 7. List your present job & highest education level: 8. List your drug allergies: (if none write none ) Please list all your medications (include over-the-counter if none write none ) on the following sheet:

4 Page 4 of 8 MEDICATION RECONCILIATION LIST (For REFERENCE only) Medication allergies: Home Medication Reported on Arrival Dosage Route Frequency Last Taken Patient Label Permanent Part of Medical Record

5 Page 5 of 8 1. List any significant hospitalization/surgeries: 2. List any significant medical conditions you have or have had in the past: 3. Circle any of the following conditions you have now or have had in the past: High blood pressure Heart attack Heart arrhythmia Heart palpitations Asthma Fibromyalgia Syndrome COPD Broken nose Deviated nasal septum Heartburn Stomach acid reflux Rheumatism/Arthritis (any type) NONE OF THE CONDITIONS LISTED ABOVE

6 Page 6 of 8 List the following for your typical night s sleep: Work/School Night Weekend/Vacation Nights Time in bed Time you try to fall asleep Time you initially do fall asleep Time you wake up for last time Time you get out of bed for the last time to start the day If you have an unusual sleep schedule, please explain (for example rotating night shifts, permanent graveyard shifts, etc.) If you have trouble sleeping, list how often you wake up, why you wake up (for example: noisy room, noisy pets, no reason, etc.), and what you do to try to fall back asleep.

7 Page 7 of 8 Circle Yes or No for each of the following sleep problems: - Do you snore? Yes No - Do you gasp in your sleep? Yes No - Do you have night sweats? Yes No - Do you have headaches related to sleep? Yes No - Do you have a pain problem that affects your sleep? Yes No - Do you have unpleasant sensations in your legs (or arms) that affect your sleep? Yes No - Do you have leg jerks or kicks that disturb your sleep or others? Yes No - Do you ever suddenly develop muscle weakness or lose muscle tone or control while fully awake? Yes No - When falling asleep or waking up, do you ever feel paralyzed or unable to move? Yes No - When falling asleep or waking up, do you ever see things or hear things that you know are not there? Yes No - Do you talk in your sleep? Yes No - Do you walk in your sleep? Yes No - Do you have violent episodes of sleep-walking? Yes No - Do you frequently wake up startled and feeling panicky? Yes No - Do you have frequent nightmares? Yes No

8 Page 8 of 8 How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done any of these things recently, try to work out how they would affect you. USE THE FOLLOWING SCALE TO CHOOSE THE MOST APPROPRIATE NUMBER FOR EACH SITUATION. PLEASE ANSWER ALL OF THE QUESTIONS. Sitting and reading Watching T.V. 0 Would never doze 1 Slight chance of dozing 2 Moderate chance of dozing 3 High chance of dozing Sitting, inactive in a public place (i.e., meeting or theater) As a passenger in a car for an hour Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few seconds in traffic