Sleep History Questionnaire

We ask our patients to complete this questionnaire prior to their appointment. You can print this page for reference.

Name:

Date of Birth:

Today’s Date:

Symptoms during sleep:

Indicate by placing a check mark if you experience any of these symptoms when sleeping or trying to sleep:

___Loud snoring

___Breathing or snoring stops during sleep

___Awaken gasping for breath

___Becomes sleep during the day

___Difficulty falling to sleep

___Difficulty remaining asleep

___Awakens too early

___My mind races with many thoughts when I try to fall asleep

___ I often worry whether or not I will be able to fall asleep

___ Fatigue

___Awaken with dry mouth

___Morning headaches

___Irritability/Depression

___Memory impairment or inability to concentrate

___Sinus trouble, nasal congestion or Post-nasal drip interfering with sleep.

___Heartburn, sour belches, regurgitation, or indigestion which disrupts sleep

___Inability to move as you are trying to go to sleep or awaken

___Vivid dreams or nightmares

___Sudden weakness or feel your body go limp when you are excited or angry

___Irresistible urge to move legs or arms

___Creeping or crawling sensation in your legs before falling asleep

___Legs or arms jerking during sleep

___Frequent urination disrupting sleep

___Sleep talking or Sleep walking

___Pain which awakens me from sleep

Questionnaire:

1.) How long have these symptoms been present? Please check

____ Between 1-3 months

____ 3-6 months

____ Over 6 months

2.) What is your neck circumference? ____________

3.) Are you on oxygen at home? _______________

4.) Do you work at night? _____________________

5.) Do you have insomnia? ____________________

Ht:___________ Wt:_________ BMI:_________

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situation, in contrast to feeling just tired? This refers to your usual way of life in recent time. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze; 1 = slight chance of dozing; 2 = moderate chance of dozing; 3 = high chance of dozing

Situation: Chance of dozing

• Sitting and reading _______
• Watching T.V. _______
• Sitting, inactive, in a public place (e.g., a theater or meeting) _______
• As a passenger in a car for an hour without a break _______
• Lying down to rest in the afternoon _______
• Sitting and talking to someone _______
• Sitting quietly after lunch with out alcohol _______
• In a car stopped at a traffic signal _______

Total: _______

(Greater than 10 indicates Sleepiness)

** If these symptoms are bothering you and your score is greater than 10 please speak with your physician and feel free to contact Southern Regional Medical Center’s Sleep Diagnostic Center at 770-909-2638.