PSDM Background Questionnaire

SLEEP QUESTIONNAIRE
Name*
First NameMiddle NameLast NameSuffix
Date of Birth*
MonthDayYear
Date
Phone Number*
Area CodePhone Number
What is your height?
Ex. 5 feet 8 inches
How much do you weigh?
lbs.
Neck Circumference
Ex. 15 inches
Who is filling in this form?*
PatientFamily MemberOther
What is the name of your primary care physician?
Primary physician phone number
Area CodePhone Number
Have you ever had a sleep study before?*
YesNo
If yes, how long ago was your sleep study?*
Less than 1 year agoLess than 2 years ago3 or more years agoI have never had a sleep study before
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 normally take you to fall asleep at night? (Guess is OK) *
MINUTES
Do you have any frequent awakenings during sleep?*
YesNo
How often?
Are awakenings related to needing to use restroom?*
YesNo
Do you snore?*
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
Have others informed you that you snore loudly, stop breathing or “gasp” while asleep?
YesNoI don't know
Do you wake up with a headache in the morning at least once a week?*
YesNoI don't know
Have you had uncomfortable sensations in your legs that worsened with prolonged rest or during the evening hours and relieved by movement?*
YesNoI don't know
Do you kick your legs or have others told you you you do while asleep?*
YesNoI don't know
Have you experienced sudden muscle weakness (e.g. legs, neck) after laughing or strong emotion?*
YesNoI don't know
Have you awoken from sleep able to look around but unable to move or speak for a short time?*
YesNoI don't know
Have you ever seen images, heard sounds, or felt something that was not present when drowsy or upon awakening from sleep?*
YesNoI don't know
Please indicate if any of the following behaviors occur during your sleep (please check all that apply):*
SleepwalkingBedwettingSeizures/Uncontrolled shaking/ twitchingDry mouthAwakening with heart palpitationsSleep talking / shouting / swearingAwakening feeling paralyzedHeartburn / RefluxFrequent nightmaresNocturnal coughExcessive sweatingTeeth grindingWaking with tongue or cheek bitten or soreNone ApplyFalling out of bedOther
How many servings of caffeine do you consume on a typical day?*
How many alcoholic beverages do you consume in an average week?*
Do you use tabacco?*
YesNo
How much?
(Packs/ week)
Surgical / Medical History*
TonsillectomyDeviated Nasal Septum SurgeryChronic Pain/ Opiate UseOrthodontia/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 Failure (CHF)GERD / Heartburn / Acid RefluxType II DiabetesHypothyroidismHigh cholesterolAllergic RhinitisCOPD/ EmphysemaAsthmaAnemiaFibromyalgiaMigraine HeadacheOther
Additional History*
Bipolar DisorderDepressive DisorderAnxiety DisorderAlcohol / Drug DependenceNoneOther

Family Sleep and Psychiatric History*

	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

Other comments on Family History
Medications and Dosage, including sleep aids, pain medication and supplements (or bring to appointment)
List allergies or adverse reactions to medications here:*
List anything else you'd like your doctor to know about you
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 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 the most 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*

	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
Total

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.
Please rate the CURRENT (LAST 2 WEEKS) SEVERITY of your insomnia problem(s).*
None Mild Moderate Severe Very Severe
Difficulty falling asleep
Difficulty staying asleep
Problems waking too early
Very satisfied Satisfied Moderately Dissatisfied Very Dissatisfied
How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?

	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?

If there are concerns regarding my health based on my answers above, I would like a sleep specialist to contact me regarding diagnostic and treatment options*
YesNo
Neurological Assessment
Please answer the following questions if you are experiencing signs and symptoms of any neurological problems. If not, you may skip to the end.
Have you ever experienced any of the following symptoms?
Uncontrollable movements, jerks or twitchesSudden fear/ anxietySensitivity to lightsStarring spellsEpisodes of derealization/ Out of body experenceFeeling of being lost even while in a familiar placeHistory of High Fever/ Febrile SeizuresConfusion/ DisorientationLoss of ConsciousnessSudden blurred or loss of visionDeja VuSudden weakness on one side of your bodyOther
Any prior history that may cause Seizures?
Traumatic head injuryCar accidentMeningitisEncephalitisStrokeBleeding in brainBrain TumorHigh feverAllergic reaction to medicationOther
Have you or anyone in your family been diagnosed with Epilepsy?
Yes, I haveA member of my family has, bit I have notYes I have as well as family membersNo family history of Epilepsy
Click submit below to send your forms.
Should be Empty:

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

SLEEP QUESTIONNAIRE

Epworth Sleepiness Scale

Insomnia Severity Index

Neurological Assessment