Sleep Disorder Diagnosis Form
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
N/A
Height
Weight
Blood Pressure
BMI
I smoke cigarettes on a regular basis. Number per day:
I drink coffee on a regular basis. Number of cups per day:
I drink alcohol before bed/as a nightcap. Number of drinks per night:
Health History
I have frequent urination at night
I eat a lot of spicy food/I get indigestion often
I am overweight
I suffer from depression
I have a history (or family history) of heart disease
I have high blood pressure
I have high cholesterol
I have diabetes
I am on medication:
Sleep History
I sleep fitfully (tossing and turning)
I snore loudly enough for others to hear/wake up
I regularly stop breathing in my sleep
I choke or gasp in my sleep
I grind my teeth while I sleep
I sweat in my sleep
I frequently wake up with headaches
I regularly get tired throughout the day
I get tired throughout the day
I get tired or doze while sitting, watching TV in the day, riding in a car, after meals, etc.
I have insomnia
I wake up multiple times a night and can't get back to sleep
I get less than 8 hours of sleep a night ( on average)
I get more than 8 hours of sleep a night (on average)
I often feel tired and unrested in the morning
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