Vital Information

Name*

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Submission Date

Date of Birth*

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Age

Referring Physician*

Primary Care Physician*

Briefly describe your main sleep problem*

For how long?*

How does this problem affect your daily life and activities?*

Have you ever had a sleep study?*

Where was this sleep study performed?*

Sleep History

When is your usual bedtime?*

:

Weekday wake time?*

:

Weekend wake time?*

:

What is your bedtime on days off?*

:

When do you wake up on days off?*

:

How long does it take you to fall asleep?*

Do you take sleeping pills?*

How long do you sleep at night on average?*

Do you have many awakenings?*

How many on average?

Is there anything in particular that awakens you?

Do you have difficulty going back to sleep when you awaken during the night?*

What is your work schedule?*

Are you required to do shift work?*

Do you nap regularly?*

What time of day and how long?

Do you snore?*

How often?

How long have you snored?

Do you seem to stop breathing at night?*

How often does this happen?

Do you wake up gasping for air or choking?*

Do you sleep on your back?*

Do you wake up feeling refreshed?*

Are you excessively sleepy during the day?*

How long have you had this sleepiness?

Does your work involve driving?*

Do you fall asleep while driving?*

Do you have an itchy, creepy/crawling sensation in your legs or urge to move your legs?*

Do you grind your teeth?*

Do you talk in your sleep?*

Do you act out your dreams?*

Please explain.

Do you experience weakness or loss of muscle control during emotions like laughing, happiness or anger?*

do you experience sagging of the jaw during emotions like laughing, happiness, or anger?*

Do you wake up unable to move your body?*

Do you wake up and see shadows of people or animals?*

Past Medical History

Please list any current/ past medical conditions for which you have been treated (e.g. Diabetes, heart or lung disease)

Do you have a chronic infection disease (such as Hepatitis/HIV)?*

List any past surgical procedures you have undergone (especially nasal/throat surgeries)

Mother's medical history (include sleep disorders if known)

Father's medical history (include sleep disorders if known)

Siblings' medical history (include sleep disorders if known)

Childrens' medical history (include sleep disorders if known)

Social History

How much do you smoke or chew tobacco?*

Do you do so close to bedtime?

How much alcohol do you drink?*

Do you do so close to bedtime?

How much caffeine do you drink?*

Do you do so close to bedtime?

What is your current or previous occupation?*

Do you have a commercial drivers license?*

License expiration date

Sleep Disorders Center New Patient Questionnaire

Vital Information

Sleep History

Past Medical History

Social History

Review of Systems

Epworth Sleepiness Scale