Adult Sleep Evaluation Questionnaire
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- Adela Neal
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1 Adult Sleep Evaluation Questionnaire Patient Name: Sex: Age: Date: Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Martial status: Single Married Divorced Widowed SSN#: Please complete the following questionnaire by placing a check in appropriate areas. My Main Sleep Complaint(s) Is: Trouble sleeping at night Being Sleepy all day Snoring for how many months/years? for how many months/years? for how many months/years? Unwanted behaviors during sleep, explain Other, explain Sleep Pattern Work Days (Weekday) Off Days (Weekends) Typical bedtime: a.m./p.m. a.m./p.m. Typical amount of time it takes to fall asleep: Typical number of awakenings per night: List any activities that you normally do During nighttime awakening(s), i.e., restroom, eat, watch TV: Typical amount of time to fall back asleep After an awakening: Typical wake up time: a.m./p.m. a.m./p.m. Desired wake up time: a.m./p.m. a.m./p.m. How do you usually awaken? i.e., alarm clock: Typical time you get out of bed: a.m./p.m. a.m./p.m. 1
2 Total amount of sleep per night: Number of naps per day: Please check all of the following statements that are true about your sleep: Sleep Habits I usually watch TV or read in bed prior to sleep I often travel across 2 or more time zones I drink alcohol prior to bedtime I smoke prior to bedtime or when I awaken during the night I eat a snack at bedtime I eat if I wake up during the night I typically wake up from sleep to go to the bathroom I have trouble falling asleep I often wake up during the night I am unable to return to sleep easily if I wake up during the night I have thoughts that start racing through my mind when I try to fall asleep I wake up early in the morning, and I am still tired but unable to return to sleep I have nightmares as an adult I experience a creeping-crawling or tingling sensation in my legs when I try to fall asleep I sweat a great deal during sleep I cannot sleep on my back Breathing I have been told that I stop breathing while I sleep I wake up at night choking, smothering or gasping for air I have been told that I snore I have been told that I snore only when sleeping on my back I have been awakened by my own snoring 2
3 Restlessness I have uncomfortable feelings in my legs and/or arms when I lie down at night I am a restless sleeper I have been told that I kick or jerk my legs and/or arms during sleep I have a hard time falling asleep because of my leg movements I have talked in my sleep as an adult I have walked in my sleep as an adult I grind my teeth in my sleep Do you have an urge to move your legs, usually accompanied or caused by uncomfortable and unpleasant sensations in legs? Does this urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity such as lying or sitting? Is this urge to move or the unpleasant sensations partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues? Is this urge to move or the unpleasant sensations worse, or only occur in the evening or night? Daytime Sleepiness I take daytime naps I have a tendency to fall asleep during the day I have had blackouts or periods when I am unable to remember what just happened I have fallen asleep while driving I have had auto accidents as a result of falling asleep while driving I fall asleep during conversations I fall asleep while watching TV I fall asleep in sedentary situations I performed poorly in school because of sleepiness I have had injuries as the result of sleepiness 3
4 Narcolepsy Have you ever.. Feel paralyzed when falling asleep? Feel paralyzed when waking up? Nearly collapse when laughing or crying? Nearly collapse when extremely emotional? Experience dreams when falling asleep or waking up? Feel refreshed after a short (10 or 15 minute) nap? I drink caffeinated beverages during the day: cups/bottles/cans per day Habits Do you smoke? Yes No if (Yes: What Amount per Day? For How Many Years Cigarettes pack(s) years Cigars years Tobacco years Do you drink alcohol? Yes No if yes: What? Frequency Amount per Week Beer daily Weekends Rare cans/week Wine Daily Weekends Rare glasses/week. Liquor daily Weekends Social History Sleep alone Share a bed with someone Share a bedroom, but have separate beds Share a dwelling, but have separate bedrooms Employment Status: Employed Unemployed Retired My job requires driving a vehicle I work with dangerous equipment or substances I am a shift worker on rotation shifts I am a permanent or long-term third shift worker I am currently a student Vital Statistics What is your: Height? feet inches Weight? What was your weight one year ago? Five years ago? 4
5 Drug Allergies: Past Sleep Evaluation and Treatment I have had a previous sleep disorder evaluation I have had a previous overnight sleep study I have had a daytime nap study I have been prescribed a CPAP or bilevel PAP machine for home use I have had surgical treatment for a sleep disorder I have previously been prescribed medication for a sleep disorder I have previously been treated for a sleep disorder Past Medical History Hypertension (high blood pressure) Heart Disease Diabetes Stomach or colon problems Lung problems/copd/asthma Reflux Tonsils removed Soft palate surgery Hepatitis/jaundice Hearing impairment Depression or severe anxiety Alcoholism Chemical dependency or abuse Fibromyalgia Adenoids removed Jaw or tongue surgery Female Stroke TIA Light Stroke Blackouts Premenstrual syndrome Menopause Seizures Male Back or joint problems (arthritis) Cancer Thyroid problems Prostate problems Erectile dysfunction/impotence List other past medical problems and dates: List Surgeries and the year _ 5
6 Check any of the following symptoms you have had in the past 12 months: Yes No Yes No Frequent headaches Frequent heartburn/indigestion Fainting or passing out Abdominal pain Sudden loss of vision or strength Frequent constipation Inability to speak Frequent diarrhea Hearing loss or ringing in ear(s) Rectal bleeding/black stools Hoarseness for more than 2-4 weeks Difficulty urinating/incontinence Nosebleeds Blood in urine Cough for more than 2-4 weeks Urinating more than 2 times per night Coughing up blood Pain in joints or bones Shortness of breath or wheezing Unusual bruising or bleeding Swelling in feet or ankles Epilepsy/seizures Chest pain, tightness, or pressure Change in wart, mole or skin growth Irregular or sudden fast heartbeat Weight loss of more than 5-10 lbs. Difficulty swallowing or food sticking Family History Has an immediate blood relative had any of the following? Yes No Relation Yes No Relation Cancer Stroke Diabetes Anxiety/Depression Hypertension Sleep Apnea Heart disease Narcolepsy Thyroid disease Other: 6
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