Sleep Questionnaire

Today's Date

Date

Name

First Name Last Name

Date of Birth

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

Headaches Dizzy Spells Seizures Fainting Memory Loss Numbness/Tingling Weakness

Gastrointestinal

Difficulty Swallowing Nausea or Vomiting Constipation Bloody or Black Stools Abdominal Pain Heartburn Vomiting Blood

Ear/Nose/Throat

Hearing Loss Ear Aches Sinus Pain TMJ Pain or Clicking (jaw) Nasal Congestion Nasal Drainage Nose Bleeds Mouth Sores Hoarseness

Heart

Chest Pain Palpitations Swelling of Feet

Musculoskeletal/Skin

Joint Pain/Swelling Muscle Pain Back Pain Neck Pain Rash

Eyes

Visual Change Eye Pain

Lung

Shortness of Breath Coughing Coughing up Blood Wheezing

Allergy/Immunology

Seasonal Allergies Eczema

Endocrine

Excessive Thirst Heat/Cold Intolerance Hot Flashes

Kidney/Bladder

Urinate Frequently Painful Urination Blood in Urine Difficulty Urinating Urinary Incontinence Sexual Difficulty

General

Fever Night Sweats Loss of Appetite Unexpected Weight Loss Weight Gain Irritability

Blood

Anemia Easy Bruising/Bleeding

Psychiatric

Anxiety/Nervousness Depression/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 Failure Heart Attack Angina Atrial Fibrillation Arrhythmia High Blood Pressure

Gastrointestinal

Liver Disease Stomach Ulcers Reflux Disease Colitis

Neurology

Stroke or Transient Ischemic Attack (TIA) Parkinson's Disease Seizure Spinal Cord Injury Head Injury

Lung Disease

COPD/Emphysema Chronic Bronchitis Asthma Pneumonia

Ear/Nose/Throat

Chronic Sinusitis Seasonal Allergies Nasal Surgery Hard/Soft Palate Surgery Tonsillectomy

If you had a tonsillectomy, what age where you at time of surgery?

Endocrine

Diabetes Thyroid Disease

If diabetic, what type?

(Type I / Type II)

Musculoskeletal

Rheumatoid Arthritis Lupus Osteoarthritis Fibromyalgia Spine/Back Surgery

Kidney/Bladder

Kidney Failure Enlarged Prostate

Psychiatric

Depression Anxiety Dementia Chemical Dependency

Miscellaneous

Peripheral Vascular Disease HIV/AIDS Anemia Blood Clots Major Trauma: Chronic Fatigue Syndrome (CFS) Leukemia/Lymphoma Cancer

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

Married Single Separated Domestic Partner Divorced Widowed

Children:

None Yes, 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.

Signature *

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Date