Patient Sleep History

Patient Sleep History
Date:*

MonthDayYear
Date
First Name:*
Middle Name:
Last Name:*
Date of Birth:*

MonthDayYear
Date
Weight:
Height:
Occupation:
This Sleep History helps your Sleep Specialist gain a more in-depth understanding of your Sleep/Medical background and the nature of your current sleep problem(s). Please complete all the questions as thoroughly as you can.
1.Describe your main sleep problem(s) and/or sleep complaint(s):
How often do these symptoms occur?

every nighttwo or more times a weekOther
How long have you been experiencing these symptoms?

2+ years1- 2 yearsseveral monthslast few weeks
I am currently on:

CPAPother PAP therapyOxygenOther
Do you have difficulty with?

ThinkingRememberingReasoning
How long does it take you to fall asleep?
How many times do you typically wake up at night?
Are your sleep habits on weekends different from the rest of the week?

NoYes, please describe below
Describe your weekend sleep habits
Do you usually:

have a bed partnersleep with someone else in your roomProvide assistance to someone during the night
Do you work split shifts or rotating shifts?

YesNo
Do you work Nights?

YesNo
Do you work Evenings?

YesNo
Do you feel refreshed after a short nap?

YesNo
How do you feel after an average night of sleep?

Drowsy, sleepy, and/or tiredRested and/or refreshed
For how long do you feel this way?

1 hour2 hours3 hours or longer
When do you feel at your best?

MorningAfternoonEvening
What time do you usually go to bed?
What time do you usually get out of bed?
14. In response to intense emotion (laughter, anger, surprise) have you felt muscle weakness in your legs, neck, arms, eyes, etc?

YesNo
If yes above, please describe emotions involved and what muscles were weakened or went limp.
Before you are fully asleep do you have very vivid, sometimes frightening, hallucination like dreams?

YesNo
Have you ever awakened and felt like your body was "paralyzed", or couldn’t move at all, even though you could breathe and see?

YesNo
Describe Your Usual Daily Routine
PLEASE CHECK ALL THAT APPLY TO YOUR USUAL ROUTINE:

Exercise regularlyEat large or spicy meals within 2-3 hours of bedtimeKeep a regular bedtime routineConsume caffeine or other stimulants within 5 hours of bedtimeGive yourself time to relax before bedtimeConsume alcohol within 2-3 hours of bedtimeTake naps longer than 45 minutes dailyExercise close to bedtimeSpend enough time in bed to allow for a full sleep periodFall asleep with the TV or Radio onFeel comfortable in your sleep environment (bed room)Go to bed when you are NOT sleepyTake hot bath/shower before bedOther
Weight Changes

Within the last three years enter total weight gained or lost
Weight Gained:
Weight Lost:
Substance Intake
Do you or someone in your household smoke? Cigarettes/cigars/pipe, etc

YesNo
Do you use tobacco?

YesNo
If yes, what type(s) and how often?
(tabacco use)
Do you use alcohol?

YesNo
If yes, how much and how often?
(alcohol use)
Do you use caffeine or other stimulants?

YesNo
If yes, how much and how often?
(caffeine or stimulant use)
ALLERGIES: Are you allergic to Latex, tape or adhesive?

YesNo
Do you have any other allergies, drug or otherwise? (Please list all known allergies in the space provided)
PAIN: Describe any pain you experience and how often:
FALLS: Have you fell in the last 5 years?

YesNo
Have you sustained any injuries from falls ?

YesNo
Sleeping Position Preferences

Choose which option you prefer, or find yourself sleeping most often
Choose one of the following six options

ONLY on my backONLY on my sidesONLY on my stomachMOSTLY on my backMOSTLY on my sidesMOSTLY on my stomach
Choose as many as apply to you.

All positionsElevated (wedge, bed, chair)On two or more pillowsIf prescribed by my doctor, YES I could strictly sleep on my left and right sides only
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. If you haven’t done some of these activities recently, please try to estimate how you would typically respond. A score of 11 or more is often sufficient for insurance companies to approve warranted services.

Use the following scale to choose the most appropriate number for each situation:

0 = would never sleep

1 = slight chance of sleeping

2 = moderate chance of sleeping

3 = high chance of sleeping
Watching TV

0123
Sitting and Reading

0123
Sitting and talking with someone

0123
Sitting quietly after a lunch without alcohol

0123
As a passenger in a car for an hour without a break

0123
In a car, while stopped for a few minutes in the traffic

0123
Sitting inactive in a public place (ex. a theater or meeting)

0123
Lying down to rest in the afternoon when circumstances permit

0123
EPWORTH SCORE
EPWORTH SCORE - Result
Current Prescription and non-prescription Medications.

	NAME OF MEDICATION	AMOUNT	HOW OFTEN	DIAGNOSIS/REASON FOR MEDICATION

Please check all that apply:

depressionsuicidealcoholismmood disorderanxiety/panicdiabetesstrokesseizuresnerve damagetremorsarthritisfibromyalgiaosteoporosisback painleg painhigh thyroidlow thyroidmenopausehot flasheshormone therapyHepatitis A/B/CHIV/AidsTuberculosisOther
Surgeries:
List any past surgeries
Other medical history not listed above:
List other medical history
Bed Partner Questionnaire

To be completed by bed partner or guardian
Name of person completing this form
Relationship to patient
Check all that apply:

Snoringsleep walking/sleep talkingtwitching/kicking legshead banging/rockingstopped breathing, choking, gaspingacting out dreamstalking during sleep/crying outapparently sleeping although behaves otherwise
Please describe any other sleep behaviors. Please Include: (1) description of behavior, (2) time it occurs, (3) how often, (4) whether it occurs every night.
Should be Empty:

Patient Sleep History

Describe Your Usual Daily Routine

Weight Changes

Substance Intake

Sleeping Position Preferences

Epworth Sleepiness Scale

Current Prescription and non-prescription Medications.

Bed Partner Questionnaire