• Texas Sleep Medicine

    Sleep Questionnaire
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  • Please check all the boxes that CURRENTLY apply to you:

  • Have you ever had any of the following medical conditions? Check all that apply. 

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  • 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

  • Mark the most appropriate box: 

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

    Rarely = Occurs monthly                           Frequently = Almost daily

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  • 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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