PSDM Background Questionnaire

BACKGROUND QUESTIONNAIRE
Please complete prior to your appointment.
Date of Birth*
MonthDayYear
Date
Name*
First NameMiddle NameLast NameSuffix
PatientOther
Please state briefly why you are requesting an appointment.*
On WEEKDAYS, when do you usually go to bed?*
:HourMinutesAM/PM Option
And wake up?*
:HourMinutesAM/PM Option
On WEEKENDS, when do you usually go to bed?*
:HourMinutesAM/PM Option
And wake up?*
:HourMinutesAM/PM Option
How long does it take you to fall asleep at night? (Guess is OK) *
MINUTES
YesNo
How often?
YesNo
YesNo
YesNoI don't know
If yes, please rate the loudness of snoring

1 2 3 4 5 6 7 8 9 10
1 is None, 10 is Loudest
YesNoI don't know
YesNoI don't know
YesNoI don't know
YesNoI don't know
YesNoI don't know
YesNoI don't know
YesNoI don't know
SleepwalkingBedwettingDry mouthAwakening with heart palpitationsSleep talking / shouting / swearingBody jerkingHeartburnFrequent nightmaresNocturnal coughExcessive sweatingTeeth grindingNone applyOther
How many servings of caffeine do you consume on a typical day?*
How many alcoholic beverages do you consume in an average week?*
YesNo
If yes, which ones and how often?
YesNo
If yes, how much?
What is your height?
Ex. 5 feet 8 inches
How much do you weigh?
lbs.
Neck circumference
Ex. 15 inches
TonsillectomyDeviated nasal septum surgeryOrthodontia/BrackesSinus surgerySurgery for sleep apnea / UPPPCoronary artery bypassCardiac angioplasty / stentsPacemaker / AICD implantationNeck surgeryBack surgeryStroke/TIAAlzheimer's / Other dementiaSeizure DisorderParkinson's diseaseHigh blood pressureAtrial fib / Cardiac arrhythmiasCongestive heart failureGERD / HeartburnDiabetes mellitusHypothyroidismHigh cholesterolAllergic rhinitisCOPDAsthmaAnemiaFibromyalgiaMigraine headacheNoneOther
Bipolar disorderDepressive disorderAnxiety disorderAlcohol / Drug dependenceNoneOther

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, incontrast to just feeling tired? This refers to your usual way of life in recenttimes. Even if you have not done some of these things recently try to workout how they would have affected you. Use the following scale to choose themost appropriate number for each situation.
0 = would never dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation

Rows	Chance of Dozing
Sitting and Reading
Watching TV
Sitting, in active in a public place (e.g. theater, or meeting)
As a passenger in a car without a break
Lying down to rest in the afternoon when circumstances permit
Sitting, talking with someone
Sitting quietly after a lunch without alcohol
In a car, while stopped a few minutes in traffic

Rows	Very satisfied	Satisfied	Moderately	Dissatisfied	Very Dissatisfied
How SATISFIED/DISSATISFIED are you with your CURRENT sleep patern?

Enter the message as it's shown*
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Should be Empty:

Rows	Sleep apnea	Narcolepsy	Insomnia	Restless Leg Syndrome	Depression	Anxiety	Bipolar Disorder	Other psychiatric disorder (list in comments)	Unknown/Not applicable
Father
Mother
Sister
Brother
Grandparents
Children

Rows	None	Mild	Moderate	Severe	Very Severe
Difficulty falling asleep
Difficulty staying asleep
Problems waking too early

Rows	Not at all	A little	Somewhat	Much	Very Much
How NOTICEABLE to others do you think your sleep problem is in terms of impairing your quality of life?
How WORRIED / DISTRESSED are you about your current sleep problem?
What extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

BACKGROUND QUESTIONNAIRE

Epworth Sleepiness Scale

Insomnia Severity Index