• BACKGROUND QUESTIONNAIRE

    Please complete prior to your appointment.
  • Date of Birth*
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  • Do you have any frequent awakenings during sleep?*
  • Are awakenings related to needing to use restroom?*
  • Have you ever had a sleep study before?*
  • Do you snore?*
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  • Have you been informed that you stop breathing or “gasp” while asleep?
  • Do you wake up with a headache in the morning at least once a week?*
  • Have you had uncomfortable sensations in your legs worsened with prolonged rest or during the evening hours and relieved by movement?*
  • Do you kick your legs while asleep?*
  • Have you experienced sudden muscle weakness (e.g. legs, neck) after laughing or strong emotion?*
  • Have you awoken from sleep able to look around but unable to move or speak for a short time?*
  • Have you ever seen images, heard sounds, or felt something that was not present when drowsy or upon awakening from sleep?*
  • Please indicate if any of the following behaviors occur during your sleep (please check all that apply):*

  • Do you use recreational drugs?*
  • Do you use tabacco?*
  • Surgical / Medical History*

  • Psychiatric History*

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  • Highest level of education so far?*

  • 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

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  • Insomnia Severity Index

    The Insomnia Severity Index has seven questions. The seven answers are added up to get a total score. For each question, please SELECT the number that best describes your answer.
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