• Patient Sleep History

    Patient Sleep History

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  • 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.



  • Describe Your Usual Daily Routine


  • Weight Changes

    Within the last three years enter total weight gained or lost
  • Substance Intake

  • Sleeping Position Preferences

    Choose which option you prefer, or find yourself sleeping most often
  • 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

  • Current Prescription and non-prescription Medications.

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  • Bed Partner Questionnaire

    To be completed by bed partner or guardian
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  • Should be Empty: