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Why are you seeing a lung/sleep doctor?
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How long have you had this problem?
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Occupational and Environmental Exposure History:
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(please circle if you worked in any of these environments)
• • •
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comments:
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Sleep History
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How many hours do you usually sleep at night?
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How many times per night do you wake up for more than three to five minutes?
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How often do you...
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have problems with sleep?
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For How Long (years)
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move when you sleep?
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dream when you sleep?
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have excessive daytime sleepiness?
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have difficulty going to sleep at night?
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have trouble staying asleep?
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use sleeping medications to help you sleep?
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make loud and disruptive noises (not snoring) when you breathe during sleep?
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sleep on your back?
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awaken with choking or the sensation of not breathing?
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awaken with heartburn?
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awaken with night sweats?
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awaken and experience heart palpitations or racing heart at night?
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awaken from sleep with a headache?
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use alcohol before bedtime to help you sleep?
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experience crawling or aching sensations in your legs while going to sleep or while sleeping?
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wake refreshed and ready to start the day?
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have difficulty doing your job because of sleepiness?
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How often is your breathing interrupted by long pauses?
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Does your partner report your breathing interrupted by long pauses?
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Do you snore loudly?
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Do you use stimulants to treat excessive sleepiness?
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Do you have difficulty concentrating during the day because of drowsiness?
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Compared to the past, your interest in sex is?
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Are you more irritable than in the past?
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Do you experience depression?
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