Questionnaire

Please complete the following questionnaire so that we may better serve your needs.

Today's Date:
 / 
 / 
Patient Name:
Patient Date of Birth
Patient Address:
Patient E-mail:*
Patient Phone Number:
Referring Physician
Referring Physician Address:
Referring Physician Phone:
Primary Physician:
Primary Physician Address:
Primary Physician Phone:
What Medications are you currently taking? Please include the medication, frequency, and time of day taken.
Current Medical Conditions: Do you have any of the following medical conditions?
Medical History: Please list any major illness or surgery and what year it took place.
Is there any family history of sleep disorders?
If "Yes" what type of sleep disorder(s)?
Patient Race (optional)
Gender
Patient Profile:
Marital Status:

How do you sleep? Please describe the sleep problems you are experiencing:
Which of the following describe the sleep problems you are having?
If "Other" please describe:
How long have you been experiencing your sleep problems?
Have you ever had a sleep consultation?
Have you ever had a sleep study?
If you've had a sleep consultation or study, please let us know:
What time do you usually go to sleep on week or work nights? (Please indicate AM or PM)
What time do you usually go to sleep on weekends or holiday nights? (Please indicate AM or PM)
How long does it usually take for you to fall asleep on week or work nights? (Please indicate minutes or hours)
How long does it usually take for you to fall asleep on weekends or holiday nights? (Please indicate minutes or hours)
What time do you usually wake up on week or work mornings? (Please indicate AM or PM)
What time do you usually wake up on weekends or holiday mornings? (Please indicate AM or PM)
On average, how many times do you awaken during the night?
Do you usually wake up feeling rested or refreshed?
Do you feel excessively sleep during the day?
How long have you felt excessively sleepy during the day?
How often do you sleep 12 hours or more at a time?
Do you snore?
Do you have a bed partner?
If you have a bed partner, please ask your bed partner to rate how loud you snore (Scale from 1 being barely audible to 10 being loud and disturbing):
1
2
3
4
5
6
7
8
9
10
Have you been told by your partner that you stop breathing in your sleep?
If "Yes" how often?
Do you wake up coughing, choking, or with a stomach acid taste?
If "Yes" how often?
Do you wake up with your heart beating rapidly or irregularly?
If "Yes" how often?
Do you wake up with a dry mouth or sore throat?
If "Yes" how often?
Do you wake up with a headache?
If "Yes" how often?
Have you experienced any weight gain over the past months or years?
If "Yes" how much weight have you gained?
Within the last year, has depression, anxiety or stress interfered with your sleep?
If "Yes" please explain what happened:
Have you had any of these experiences while sleeping?
If "Yes" how often?
Do you walk in your sleep?
If "Yes" how often?
Do you grind or clinch your teeth at night?
If "Yes" how often?
Do you experience an uncomfortable feelings in your legs, with an urge to move your legs?
If "Yes" how often?
Does moving your legs give you a sense of relief from these uncomfortable feelings?
If "Yes" how often?
Has your bed partner complained about any kicking throughout your sleep?
If "Yes" how often?
Have you ever felt sudden muscle weakness when you laughed, got angry, surprised, or during sex?
If "Yes" please explain what happened:
Have you ever been unable to move your body just as you were falling asleep or waking up?
If "Yes" please explain what happened:
Have you ever had visual hallucinations or vivid dreams just as you were falling asleep or waking up?
If "Yes" please explain what happened:

Lifestyle

Do you currently smoke?
If "Yes" how long have you smoked? (Please indicate in years)
If "Yes" what do you smoke?
If "Yes" how much do you smoke in a 24 hour period?
Do you drink caffeinated beverages (Included coffee, tea, or caffeine sodas)?
If "Yes" how many 8oz cups of caffeinated beverages do you drink per day (Glasses,Cups, Cans)?
Do you regularly drink alcohol?
If "Yes" how much do you drink on a week or work nights?
If "Yes" how much do you drink on weekend or holidays?
Do you feel depressed?
Have you experienced a change in personality or overall mood in the past year?
If "Yes" please describe how you have changed:
Have you ever seen a psychiatrist, or professional counselor?
Are you currently seeing a psychiatrist, psychologist or professional counselor?
How often do you exercise?
If "Yes" what kind of exercise activity?

Work Habits

What is your occupation?
Length of employment
What is your current position?
What shift do you work?
What are your work hours Monday through Friday (Please indicate start time and end time)?
What are your work hours on Saturday (Please indicate start time and end time)?
What are your work hours on Sunday (Please indicate start time and end time)?

The Epworth Sleepiness Scale

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 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 the situation: ( 1=would never doze, 2=slight chance of dozing, 3=moderate chance of dozing, 4= high chance of dozing

Sitting and reading.
1
2
3
4
Sitting, inactive, in a public place (theater, meeting, etc.).
1
2
3
4
As a passenger in a car for an hour without a break.
1
2
3
4
Lying down to rest in the afternoon when circumstances permit.
1
2
3
4
Sitting and talking to someone.
1
2
3
4
Sitting quietly after lunch without alcohol.
1
2
3
4
In a car, while stopped for a few minutes in traffic.
1
2
3
4
Watching TV.
1
2
3
4
© Pacific Sleep Medicine 2024.