Sleep Questionnaire for McLaren Greater Lansing

Name*:

Date of Birth*:

Age*:

Gender*:

Male

Female

Height (in inches)*:

Weight (in pounds)*:

Weight 1 year ago (in pounds)*:

Weight 5 years ago (in pounds)*:

SLEEP SCHEDULE (Please provide the following information, circle answer where appropriate)

What time do you go to bed on Weekdays? *

AM or PM? *

Weekends? *

AM or PM? *

What time do you wake up on Weekdays? *

AM or PM? *

Weekends? *

AM or PM? *

Do you nap? *

YES

How often do you nap (times per week)?

How long are the naps (in minutes)?

Do you awaken refreshed? *

YES

Are you a shift worker? *

YES

If yes, what kind of shift do you work?

What is your occupation? *

If retired, when?

Previous jobs held:

SNORING/BREATHING HISTORY (Please select appropriate answer)

Do you snore? *

Do Not Know	Sometimes
Yes	No

Does your sleep position affect your snoring? *

YES

Have you awakened choking or short of breath? *

YES

Has anyone noticed that you stop breathing while asleep? *

YES

Do you awaken often to urinate during the night? *

YES

Do you awaken refreshed in the morning? *

YES

Do you awaken with an acid or sour taste in your mouth? *

YES

Do you have difficulty sleeping on your back? *

YES

SLEEP HISTORY (Please check appropriate answer)

Do you have difficulty falling asleep? *

YES

Do you have difficulty staying asleep? *

YES

Do you wake up too early and cannot get back to sleep? *

YES

Do you have thoughts racing through your mind that make it difficult to sleep? *

YES

Have you fallen asleep unexpectedly? *

YES

Have you ever fallen asleep while driving? *

YES

Have you experienced sleep attacks (a sudden irresistible urge to sleep)? *

YES

Have you experienced sudden muscle weakness in response to emotions? *

YES

Have you experienced an inability to move while falling asleep or waking up? *

YES

Have you experienced dream-like images or sounds while falling asleep or waking up? *

YES

Do you kick or jerk your arms or legs during sleep? *

YES

Do you have a creepy, crawly sensation in your legs when lying down? *

YES

Do you have leg cramps (Charley horse)? *

YES

Do you grind your teeth? *

YES

Do you talk in your sleep? *

YES

Do you have nightmares? *

YES

Have you ever acted out your dreams? *

YES

Have you ever bitten your tongue while sleeping? *

YES

MEDICAL/SURGICAL HISTORY (please check answer and fill in the blank where appropriate)

Have you ever had a sleep study in the past? *

Yes

If yes, when?

If yes, where?

Do you use home CPAP or BIPAP? *

Yes

If yes, what pressure setting?

Do you use home oxygen? *

Yes

If yes, what liter-flow setting? *

Do you have a pacemaker? *

Pacemaker	Pacemaker/defibrillator
No

Have you ever had a tonsillectomy? *

Yes

Have you ever had sinus or nasal surgery? *

Yes

Have you ever broken your nose? *

Yes

Have you ever had any type of head injury? *

Yes

Have you had surgery to promote weight loss? *

Yes

If yes, when?

Please check the appropriate box if you have a history of any of the following health problems: *

If Other, please specify:

Family History Does any member of your family have the following?

Sleep Apnea? *

Yes

If yes, Relationship:

Narcolepsy? *

Yes

If yes, Relationship:

Seizure disorder? *

Yes

If yes, Relationship:

Depression? *

Yes

If yes, Relationship:

Hypertension? *

Yes

If yes, Relationship:

Stroke? *

Yes

If yes, Relationship:

Allergies (please list):

List current medication 1 - give medication name, dose (mg) and number of times taken per day:

List current medication 2 - give medication name, dose (mg) and number of times taken per day:

List current medication 3 - give medication name, dose (mg) and number of times taken per day:

List current medication 4 - give medication name, dose (mg) and number of times taken per day:

List current medication 5 - give medication name, dose (mg) and number of times taken per day:

List current medication 6 - give medication name, dose (mg) and number of times taken per day:

SOCIAL HISTORY (please check boxes and fill in the blank where appropriate)

Do you smoke? *

Yes

If yes, Packs per day?

If yes, How long?

Have you smoked in the past? *

Yes

If yes Packs per day?

If yes, how long?

Do you drink beer - wine - liquor? *

Yes

If yes, how much:

WORTH SLEEPINESS SCALE-How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired. Please check the most appropriate answer using the following scale and total your points

Sitting and reading: *

0 = never

1 = occasionally

2 = often

3 = usually

Watching TV: *

0 = never

1 = occasionally

2 = often

3 = usually

At a public place like a theater or meeting: *

0 = never

1 = occasionally

2 = often

3 = usually

While a passenger in a car for one hour or more: *

0 = never

1 = occasionally

2 = often

3 = usually

Lying down in the afternoon: *

0 = never

1 = occasionally

2 = often

3 = usually

Sitting and talking with someone: *

0 = never

1 = occasionally

2 = often

3 = usually

Sitting down after lunch: *

0 = never

1 = occasionally

2 = often

3 = usually

Stopped at a stoplight: *

0 = never

1 = occasionally

2 = often

3 = usually

Total score out of 24 (please add):

Do you have any physical limitations we should be aware of?

Captcha*