Patients Form - Pulmonary Clinics of Scottsdale

Sleep Questionnaire

Please complete the following information and bring it with you on the appointed date and time. This information is essential for the doctor to make a final diagnosis. Thanks for your cooperation.

Name

Date

Referring Physician

Height

Weight

What type of sleep problem are you having?

Have you been evaluated in a sleep clinic previously?

Have you previously been diagnosed with sleep apnea?

Have you had surgery for either snoring or sleep apnea?

Typical Sleep Habits

What time do you typically go to bed?

What time do you typically awaken?

Do you feel refreshed when you awaken for the day?

Do you use an alarm or awaken on your own?

How long does it take you to fall asleep on a typical night?

Is there anything that prohibits you from falling, asleep or staying asleep?

How many times do you think you awake at night?

Are you aware of what awakens you at night?

Once you are awakened, how long does it take you to fall back asleep?

Do you take naps? Yes or No

Please Click the most appropriate answer

Snoring
Yes No I Don't Know

Has anyone ever commented on your snoring?
Yes No I Don't Know

Breathing pauses when you sleep
Yes No I Don't Know

Wake up choking or gasping from sleep
Yes No I Don't Know

Wake up with shortness of breath
Yes No I Don't Know

Nasal / sinus congestion
Yes No I Don't Know

Morning headaches
Yes No I Don't Know

Heartburn interfering with sleep
Yes No I Don't Know

Grind teeth while sleeping
Yes No I Don't Know

Nightmares
Yes No I Don't Know

Sleepwalking
Yes No I Don't Know

Acting out dreams
Yes No I Don't Know

Do you experience leg tension aching or crawling sensation in your legs?
Yes No I Don't Know

Are you ever told that you kick / jerk at night?
Yes No I Don't Know

Hallucinations when falling asleep or upon awakening
Yes No I Don't Know

Momentary complete paralysis when falling asleep or upon awakening
Yes No I Don't Know

While awake, do you have episodes of muscle weakness brought on by strong emotions?
Yes No I Don't Know

As s result of poor sleep do you have poorer concentration, short-term memory loss, or impaired thinking?
Yes No I Don't Know

Epworth Sleepiness scale

How likely are you to fall asleep or doze off in the following situation? This refers to your usual way of life in recent times. Use the following scale and choose the most appropriate number for each of the situations.
0-Never 1-Slight chance 3-High chance 2-Moderate chance

SITUATION

RATING

Gitting and Reading

Watching TV

Sitting, Inactive, in a public place

As a passenger in a car for i hour without a break

Lying down to rest when circumstances permit

Talking with someone

Sitting quietly after a meal (without alcohol)

While driving a car and stopping for a few minutes in traffic

Total

Please Click the most appropriate answer

I have trouble falling asleep
Yes No

I wake up during the night and have difficulty getting back to sleep
Yes No

I have frequent awakening at night but no difficulty returning to sleep
Yes No

I wake up to early in the morning and am unable to get back to sleep
Yes No

I have difficulty waking in the morning
Yes No

Daytime fatigue is a problem for me
Yes No

HEALTH HABITS

Do you currently smoke?__Yes__No If Yes, then then what?

How much and how long have you smoked?__ Years __ Packs per day

Approximately how much caffeine do you consume in a day?

Coffee cups per day

Tea cups per day

Soft drinks cups per day

Do you currently drink alcohol?__Yes__No

How many drinks do you consume on a weekday?

How many drinks do you consume during the weekend day or day off from work?

MEDICATIONS

Medications you currently take (please include "over the counter", vitamins, and herbal substances)

Medication

Dosage

How Often

Reason

Have you taken any medications (prescription /over the counter) to help you sleep?__Yes__No

A. If so, please list medication, date take and effectiveness:

Do you use any of the "over-the-counter" medicines? (i.e... allergy, cold medicines)__Yes__No

A. If so, please list medication, date take and effectiveness:

Do you use any drugs recreationally? Yes__No

A. If so, please list the drug taken:

ALLERGIES

Are you allergic to or have had a "bad reaction" to any medications or other substance (such as latex)?__Yes__No If yes, please list medication or substance and reaction below:

Medication/Substance

Reaction

PAST MEDICAL HISTORY

Psychiatric
Depression
Anxiety
Dementia
Alcoholism

Weight
Gain
Loss
Amount
Time Frame

Lung Disease
COPD, Emphysema
Asthma

Ear / Nose / Throat
Chronic Sinusitis
Seasonal Allergy
Nasal Surgery
Tonsillectomy

Neurology
Stroke or TIA'S
Parkinson's Disease
Seizure
Head Injury

Gastrointestinal
Reflux Disease
Heartburn

Endocrine
Diabetes
Thyroid Disease

Please describe any prior nasal, oral, throat, jaw, head and neck surgeries:

Please list any past surgeries or illness not mentioned above: