Sleep Questionnaire

Texas Sleep Medicine

Sleep Questionnaire
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
What is your main sleep complaint and how long has it occurred?
Have you ever had a sleep study before? If yes, please tell us when and where it occurred
Please check all the boxes that CURRENTLY apply to you:
Neurological

HeadachesDizzy SpellsSeizuresFaintingMemory LossNumbness/TinglingWeakness
Gastrointestinal

Difficulty SwallowingNausea or VomitingConstipationBloody or Black StoolsAbdominal PainHeartburnVomiting Blood
Ear/Nose/Throat

Hearing LossEar AchesSinus PainTMJ Pain or Clicking (jaw)Nasal CongestionNasal DrainageNose BleedsMouth SoresHoarseness
Heart

Chest PainPalpitationsSwelling of Feet
Musculoskeletal/Skin

Joint Pain/SwellingMuscle PainBack PainNeck PainRash
Eyes

Visual ChangeEye Pain
Lung

Shortness of BreathCoughingCoughing up BloodWheezing
Allergy/Immunology

Seasonal AllergiesEczema
Endocrine

Excessive ThirstHeat/Cold IntoleranceHot Flashes
Kidney/Bladder

Urinate FrequentlyPainful UrinationBlood in UrineDifficulty UrinatingUrinary IncontinenceSexual Difficulty
General

FeverNight SweatsLoss of AppetiteUnexpected Weight LossWeight GainIrritability
Blood

AnemiaEasy Bruising/Bleeding
Psychiatric

Anxiety/NervousnessDepression/Sadness
Current Weight
lbs
Height
Feet Inches
Weight One Year Ago
lbs
Weight Five Years Ago
lbs
Medication allergies and associated reaction
Please list all the medications you currently take (Including over-the-counter):
(Medication / Dose (i.e., mg/strength) / Times per day taken / Prescribing doctor (if prescription)
Have you ever had any of the following medical conditions? Check all that apply.
Heart Disease

Heart FailureHeart AttackAnginaAtrial FibrillationArrhythmiaHigh Blood Pressure
Gastrointestinal

Liver DiseaseStomach UlcersReflux DiseaseColitis
Neurology

Stroke or Transient Ischemic Attack (TIA)Parkinson's DiseaseSeizureSpinal Cord InjuryHead Injury
Lung Disease

COPD/EmphysemaChronic BronchitisAsthmaPneumonia
Ear/Nose/Throat

Chronic SinusitisSeasonal AllergiesNasal SurgeryHard/Soft Palate SurgeryTonsillectomy
If you had a tonsillectomy, what age where you at time of surgery?
Endocrine

DiabetesThyroid Disease
If diabetic, what type?
(Type I / Type II)
Musculoskeletal

Rheumatoid ArthritisLupusOsteoarthritisFibromyalgiaSpine/Back Surgery
Kidney/Bladder

Kidney FailureEnlarged Prostate
Psychiatric

DepressionAnxietyDementiaChemical Dependency
Miscellaneous

Peripheral Vascular DiseaseHIV/AIDSAnemiaBlood ClotsMajor Trauma:Chronic Fatigue Syndrome (CFS)Leukemia/LymphomaCancer
If you have a history of Cancer, what type?
(i.e., breast, colon)
Please list any past surgeries or illnesses not mentioned above:
Type of Surgery or illness / Date

Click the appropriate boxes if your family member have had any of the following conditions:

	Father	Mother	Siblings	Children
Cancer
Diabetes
High Blood Pressure
Stroke
Heart Disease
Insomnia
Narcolepsy
Snoring
Sleep Apnea
Restless Legs

Occupation
What is your work schedule?
Race
Ethnicity
Marital status

MarriedSingleSeparatedDomestic PartnerDivorcedWidowed
Children:

NoneYes, but not living with me
If children live with you, what are their ages?
If you drink alcohol, how much?
If you use tobacco products, how much?
If you use marijuana, how much?
If you use illicit substances, which one(s) and last used?
Do you currently drink caffeinated beverages?
If yes, how many per day?
Cans of Soda
Cups of Coffee
Cups of Tea
Energy drinks
At what time of day/night do you have your last caffeinated beverage?
On weekdays/work days, what time do you go to bed?
On weekdays/work days, what time do you get out of bed?
On weekends/days, what time do you go to bed?
On weekends/days, what time do you get out of bed?
What would be your ideal schedule?
Time you go to bed/Time you get our of bed
Do you eat, argue, worry, write, and/or read in bed? If yes, please specify:
Do you have difficulty falling or staying asleep? If yes, please specify:
(How long does it take? # minutes/hours? # of nights weekly?)
Did you have any sleep problems as a child? If yes, please specify:
For the following situations, indicate the chance of dozing or falling asleep (not feeling tired) by using the scale below:

0 = Would never doze

1 = Slight chance of dozing

2 = Moderate chance of dozing

3 = High chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g., a meeting or a theatre)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes in traffic
Total =
Have you ever had an accident or near miss because of dozing while driving? If yes, when an describe:
Mark the most appropriate box:

Never = It does not occur Occasionally = Occurs one or more times a week

Rarely = Occurs monthly Frequently = Almost daily

Question

	Never	Rarely	Occasionally	Frequently
Do you currently have intense nightmares or night terrors?
Do you ever have exceptionally vivid dreams while falling asleep?
Do you have SUDDEN muscle weakness when you laugh or are angry?
Do you feel paralyzed as you are falling asleep or waking up?
Do you currently grind your teeth at night?
Do you currently talk in your sleep?
Do you currently walk in your sleep?
Do you awaken to urinate?
Do you currently have incontinence of urine during sleep?
Does your bed partner complain about your excessive moving?
Do you awaken yourself by kicking your legs?
Has your bed partner ever complained of leg kicks?
Do you have a restless sense of discomfort in your legs while resting or before falling asleep?
Have you been told you stop breathing during sleep?
Do you snore?
Do you ever awaken gasping for air?
Do you awaken with a dry mouth?
Do you awaken with nasal congestion?
Do you awaken with morning headaches?
Do you awaken with a sore throat?
Do you have night sweats?
Do you have heartburn at night?
Do you feel unrefreshed after sleeping?
Are you ever confused in the morning?
Do you feel depressed?
Do you have problems with memory/concentration?
Do any of your children and/or pets sleep in the bedroom with you?

Please list the names / addresses / phone numbers of the doctors you would like to receive reports from our clinic:
***Please use providers full name when listing names.***
I hear by give permission to Texas Sleep Medicine to release my medical records to the above providers. This information may be disclosed by fax, by mail, or by oral communication. I understand that my records are protected and cannot be disclosed without this written consent. I also understand that I may revoke this consent by written communication except to the extent that action has already been taken in reliance on it (i.e. information already disclosed My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand. This authorization shall remain valid until revoked by me in writing.
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