Sleep Medicine Follow Up Form

Sleep Medicine Follow Up Form
Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your usual bedtime
Hour Minutes
AM/PM Option
How long does it take to fall asleep?
In minutes
How many times do you wake up at night?
0,1,2,3,4
You usually wake up
Hour Minutes
AM/PM Option
Which ones of the followings do you currently use?
Rows Currently use? Type/Amount/Frequency How Long?
Caffeine
Tobacco
Alcohol
Please use the following scale to choose the most suitable number for you for each statements:
0 = Never doze
1 = Low chance of dozing
2 = Slight chance of dozing
3 = Moderate chance of dozing
4 = High chance of dozing
5 = Always dozing
Sitting and reading

0
1
2
3
4
5
0 is Never, 5 is Always
Watching TV

0
1
2
3
4
5
0 is Never, 5 is Always
Sitting, inactive in a public place

0
1
2
3
4
5
0 is Never, 5 is Always
As a passenger in a car for an hour without a break

0
1
2
3
4
5
0 is Never, 5 is Always
Lying down to rest in the afternoon when circumstances permit

0
1
2
3
4
5
0 is Never, 5 is Always
Sitting and talking to someone

0
1
2
3
4
5
0 is Never, 5 is Always
Sitting quietly after a lunch without alcohol

0
1
2
3
4
5
0 is Never, 5 is Always
In a car, while stopped for a few minutes in traffic (as a driver)

0
1
2
3
4
5
0 is Never, 5 is Always
Should be Empty:

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