Sleep Study Questionnaire Form for McLaren Clarkston

This is McLaren Oakland and McLaren Clarkston Sleep Questionnaire Form. This is a secure form. Please call 248-922-6840 if you have any questions. Use the 'tab' key or mouse to move to the next question. The 'enter' key will submit your information.
*Name:**	* Please enter your name.
*Email:**	* Please enter a valid Email Address.
*Date of Birth:**	* Please enter your date of birth.
*Age:**	* Please enter your age.
*Gender:**	Male Female * Please select an option.
*Height (in inches):**	* Please enter your height.
*Weight (in pounds):**	* Please enter your weight.
*Weight 1 year ago (in pounds):**	* Please enter your weight one year ago.
*Weight 5 years ago (in pounds):**	* Please enter your weight five years ago.
SLEEP SCHEDULE (Please provide the following information, circle answer where appropriate)
*What time do you go to bed on Weekdays?:**	* Please enter the time you go to bed on weekdays.
*AM or PM?:**	AM PM * Please select an option.
*What time do you go to bed on Weekends?:**	* Please enter the time you go to bed on weekends.
*AM or PM?:**	AM PM * Please select an option.
*What time do you wake up on Weekdays?:**	* Please enter the time you wake up on the weekdays.
*AM or PM?:**	AM PM * Please select an option.
*What time do you wake up on Weekends?:**	* Please enter the time you wake up on the weekends.
*AM or PM?:**	AM PM * Please select an option.
*Do you nap?:**	YES NO * Please select an option.
How often do you nap (times per week)?:
How long are the naps (in minutes)?:
*Do you awaken refreshed?:**	YES NO * Please select an option.
*Are you a shift worker?:**	YES NO * Please select an option.
If yes, what kind of shift do you work?:
*What is your occupation?:**	* Please enter your occupation.
If retired, when?:
Previous jobs held:
SNORING/BREATHING HISTORY (Please select appropriate answer)
*Do you snore?:**	Do Not Know Sometimes Yes No * Please select an option.
*Does your sleep position affect your snoring?:**	YES NO * Please select an option.
*Have you awakened choking or short of breath?:**	YES NO * Please select an option.
*Has anyone noticed that you stop breathing while asleep?:**	YES NO * Please select an option.
*Do you awaken often to urinate during the night?:**	YES NO * Please select an option.
*Do you awaken refreshed in the morning?:**	YES NO * Please select an option.
*Do you awaken with an acid or sour taste in your mouth?:**	YES NO * Please select an option.
*Do you have difficulty sleeping on your back?:**	YES NO * Please select an option.
SLEEP HISTORY (Please check appropriate answer)
*Do you have difficulty falling asleep?:**	YES NO * Please select an option.
*Do you have difficulty staying asleep?:**	YES NO * Please select an option.
*Do you wake up too early and cannot get back to sleep?:**	YES NO * Please select an option.
*Do you have thoughts racing through your mind that make it difficult to sleep?:**	YES NO * Please select an option.
*Have you fallen asleep unexpectedly?:**	YES NO * Please select an option.
*Have you ever fallen asleep while driving?:**	YES NO * Please select an option.
*Have you experienced sleep attacks (a sudden irresistible urge to sleep)?:**	YES NO * Please select an option.
*Have you experienced sudden muscle weakness in response to emotions?:**	YES NO * Please select an option.
*Have you experienced an inability to move while falling asleep or waking up?:**	YES NO * Please select an option.
*Have you experienced dream-like images or sounds while falling asleep or waking up?:**	YES NO * Please select an option.
*Do you kick or jerk your arms or legs during sleep?:**	YES NO * Please select an option.
*Do you have a creepy, crawly sensation in your legs when lying down?:**	YES NO * Please select an option.
*Do you have leg cramps (Charley horse)?:**	YES NO * Please select an option.
*Do you grind your teeth?:**	YES NO * Please select an option.
*Do you talk in your sleep?:**	YES NO * Please select an option.
*Do you have nightmares?:**	YES NO * Please select an option.
*Have you ever acted out your dreams?:**	YES NO * Please select an option.
*Have you ever bitten your tongue while sleeping?:**	YES NO * Please select an option.
MEDICAL/SURGICAL HISTORY (please check answer and fill in the blank where appropriate)
*Have you ever had a sleep study in the past?:**	Yes No * Please select an option.
If yes, when?:
If yes, where?:
*Do you use home CPAP or BIPAP?:**	Yes No * Please select an option.
If yes, what pressure setting?:
*Do you use home oxygen?:**	Yes No * Please select an option.
If yes, what liter-flow setting?:
*Do you have a pacemaker?:**	Pacemaker Pacemaker/defibrillator No * Please select an option.
*Have you ever had a tonsillectomy?:**	Yes No * Please select an option.
*Have you ever had sinus or nasal surgery?:**	Yes No * Please select an option.
*Have you ever broken your nose?:**	Yes No * Please select an option.
*Have you ever had any type of head injury?:**	Yes No * Please select an option.
*Have you had surgery to promote weight loss?:**	Yes No * Please select an option.
If yes, when?:
*Please check the appropriate box if you have a history of any of the following health problems::**	Hypertension Heart Attack Congestive Heart Failure Cardiac Arrhythmias Diabetes Lung problems/COPD/Asthma Stroke/TIA Seizures Depression Nasal problems/chronic nasal congestion Chronic Pain * Please select an option.
*Medications::**	* Please enter your medications.
Additional Comments:
*Doctor/NP/PA::**	* Please enter your doctor's name.
*Preferred Pharmacy::**	* Please enter your preferred pharmacy.
*Pharmacy Phone Number::**	* Please enter your pharmacy's phone number.

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