CHIEF SLEEP COMPLAINT
MEDICAL HISTORY
SOCIAL HISTORY
WORK SCHEDULE
FAMILY HISTORY
(Does anyone in your immediate Family have any of the following?)
SLEEP MEDICATIONSDo you currently use or have used in the past any of the following medications for sleep? Please check all that apply
SURGICAL HISTORY
SLEEP-RELATED SYMPTOMSPlease answer by checking YES or NO
SLEEP-WAKE SCHEDULEPlease describe your typical sleep period
WeekDAYS
FATIGUE
EPWORTH SLEEPINESS SCALEHow likely are you to fall asleep in the following situations?
0 = Never 1 = slight chance 2 = moderate chance 3 = high chance