Sleep Questionnaire

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Name

Birth date

Email

In your own words, please describe your sleep problem:

How long have you had this problem?

How would you rate your quality of sleep?

Have you ever been evaluated for sleep problems? When?

Have you ever been treated for sleep problems?

Describe treatment & results:

Height

Current Weight

Neck size (men)

How much did you weigh 1 year ago?

5 years ago?

10 years ago?

What time do you typically go to bed?

How long till you fall asleep?

What time do you usually get up for the day?

If you are working, what shift do you usually work?

Do you wake up during the night? YesNo

If yes, how many times, on average?

If yes, please explain

Do you snore?YesNo Do you think you may gasp, choke, or stop breathing while you are asleep? YesNo Is it difficult to wake up in the morning because you are still sleepy? YesNo Do you fall asleep at inappropriate times during the day, such as while driving, watching TV, talking to another person, or while at work? YesNo

Do you often have difficulty falling asleep?YesNo

Do you ever feel as if you cannot "turn your brain off" at night?YesNo

Do you get pain in your legs when you are trying to sleep?YesNo

Do you think you may kick your legs while you are asleep?YesNo

Do you ever "act out" your dreams during sleep?YesNo

Does anyone in your family have a sleep disorder?YesNo

Do you think you may be depressed - or has any physician ever said you might be depressed? YesNo

Are you taking medicines for depression?YesNo

Do you often suffer from: Poor concentrationPoor judgmentMemory lossIrritability

Before bed, do you Drink alcoholTake any sleep aid product Do you sleep with oxygen or any other medical device? YesNo

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation:

0 = would never dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Sitting & reading

Watching TV

Sitting, inactive in a public place like a theatre, a waiting room, or a meeting

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

Cardiac

Please check if yes, Have you ever had Chest discomfort at restChest discomfort with exerciseFrequent palpitationsIrregular heart beats or murmursSwelling of your feet and/or anklesShortness of breath while sleeping?Do you sleep sitting up?Do you sleep with more than one pillow?