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Patient Questionaire

Location:
 
           
Please answer these questions regarding your sleep habits as completely as possible. Either submit the completed form online or download it and bring it to your scheduled study. You may receive help from your spouse, bed-partner, or roommate if necessary.
Be sure to select sleep center location above and press the "Submit" button when finished.
           
Name:
  

D.O.B.:
  
Measurements:
  

Neck Size

     
Referring Physician:
  

     
Date of Evaluation:
        
Main Complaint:
  

   
Reason for Study:
  

 

 

     
 
What would you describe your sleep as? (Please check the appropriate items.)
   
Difficulty in falling asleep
Waking up too early
Difficulty in staying asleep
Difficulty staying awake during day time
Nightmare / Unusual dreams
Unusual movements during sleep
Sleep Walking
Unrefreshed sleep
Snoring
Bed Wetting
         
   
Sleep/Day Schedule
   
1.
What is your usual bedtime?
 
Get up time?
2.
About how many hours do you sleep each night?
3.
About how long does it take you to fall asleep?
4.
About how many times do you wake up each night?
5.
How long is your longest wake?
6.
Do you go back to sleep easily after waking in the middle of the night?
7.
What are your work hours?
8.
Do you work variable / rotating shifts?
If so, what are they?
         
   
Symptoms
   
1.
Is your bed partner disturbed by your sleep problem?
2.
Do you feel drowsy or sleepy in any of these situations? (please check appropriate items)
Eating meals
Driving
Watching television
Talking in a group
Reading
In church, watching movie / theater / play
3.
Does your sleepiness during daytime interfere with your ability to function normally?
4.
Have you ever been involved in an automobile accident due to sleepiness while driving?
5.
Do you take any naps?
6.
Do you snore?
7.
Have you been told that you do any of these in sleep? (check appropriate items)
Stop breathing while sleeping
Walk in your sleep
Wake up from sleep snorting or choking
Grind your teeth
8.
Do you wake up in the morning with headaches or dry mouth?
9.
Do you feel fresh in the morning when you wake up?
10.
Do you have any problems with sexual functioning?
11.
Do you experience vivid dream like images while falling asleep or waking from a nap?
12.
Do you dream during naps?
13.
Have you ever felt paralyzed while falling asleep or awakening from a nap?
14.
Have you ever had a feeling of weak knees when you laugh?
15.
Do you experience creeping, crawling, or aching sensations in your legs, or inability to keep your legs still?
  If so, does it keep you from falling asleep?
16.
Do you watch a clock, watch television, have racing thoughts, or worry about the next day at the time of falling asleep?
17.
Do you exercise before going to sleep?
         
   
Medical History
   
1.
Do you have any of these: (check all that apply)
High blood pressure
Heart attack / Open heart surgery
Asthma / emphysema
Cancer
Diabetes
Epilepsy / Seizures / Stroke
2.
Do you have any other medical problems?
 
         
   
Social History
   
1.
How much of these liquids do you drink on a daily basis? (list in cups, cans, etc.)
Coffee
Soft drinks – caffeinated / caffeine free
Tea
Wine
Beer
Liquor
2.
Do you smoke on a regular basis?
3.
If yes, how many packs / day?
         
   
Medication History
   
1.
Do you take any medications including over the counter medications to help you fall asleep or stay awake?
 
If yes, list names:
2.
List all current medications:
 
What is your weight now?
Six months ago?
Two years ago?
 
 
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See our Terms & Conditions page for additional information.


Our Sleep Centers:
The Sleep Disorders Institute of Chandler
70 North McClintock Drive
Suite 4
Chandler, AZ 85266
480-785-0564
480-753-4709 Fax
877-427-0870 Toll Free
info@sleeppd.com
The Sleep Disorders Center of Perrysburg
1090 W. South Boundary St. Suite 300
Perrysburg, OH 43551
877-427-0870 Toll Free
419-872-3660
419-872-3662 Fax
info@sleeppd.com
DME
866-427-0099 Toll Free
419-872-3662 Fax
dme@sleeppd.com
The Sleep Disorders Center of Lambertville
3608 Sterns Rd.
Lambertville, MI 48144
734-568-6068
734-568-6069 Fax
877-427-0870 Toll Free
info@sleeppd.com
Hardin Memorial Hospital Sleep Center
921 E. Franklin St.
Kenton, OH 43326
877-427-0870
St. Francis Hospital Sleep Center
401 N. Broadway
Green Springs, OH 44836
877-427-0870