Sleep Disorder Diagnosis Form

Sleep Disorder Diagnosis Form
Name
First NameLast Name
Date of birth
MonthDayYear
Date
Gender
MaleFemaleN/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 nightI eat a lot of spicy food/I get indigestion oftenI am overweightI suffer from depressionI have a history (or family history) of heart diseaseI have high blood pressureI have high cholesterolI have diabetesI am on medication:
Sleep History
I sleep fitfully (tossing and turning)I snore loudly enough for others to hear/wake upI regularly stop breathing in my sleepI choke or gasp in my sleepI grind my teeth while I sleepI sweat in my sleepI frequently wake up with headachesI regularly get tired throughout the dayI get tired throughout the dayI get tired or doze while sitting, watching TV in the day, riding in a car, after meals, etc.I have insomniaI wake up multiple times a night and can't get back to sleepI 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
Should be Empty: