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SLEEP SCHEDULE
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Weekday Bedtime
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Weekday Wake time
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Weekends Bedtime
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Weekends Wake time
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Do you wake up feeling rested?
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Do you currently use CPAP treatment at night?
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Pressure:
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Do you have rotating or night shift work?
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How long does it take you to go to sleep?
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How many times a night do you wake up from sleep?
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Do you fall back to sleep easily?
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Do you nap?
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If so, how often?
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SLEEP HISTORY
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Do you experience excessive daytime sleepiness?
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Are you a restless sleeper?
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Has anyone told you that you snore?
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For how long?
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Do you snore sleeping in all positions?
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If no, which position(s)
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Has your family told you that you quit breathing at night?
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For how long?
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Have you ever awakened gasping for breath?
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For how long?
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Do you awaken with mouth dryness?
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For how long?
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Do you have morning headaches?
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For how long?
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Has your weight changed in the last 5 years?
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Gained
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Lost
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Do you have "tingly" legs and feel as if you have to move them?
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For how long?
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Do you kick your legs at night?
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For how long?
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Do you sleep better away from your own bed? (ie: vacation)
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For how long?
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Do you have pain that bothers you at night?
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For how long?
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Do you grind your teeth in your sleep?
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For how long?
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Do you sleep walk?
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For how long?
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Do you talk in your sleep?
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For how long?
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Have you ever experienced periods in which you feel paralyzed while you are going to sleep or waking up?
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For how long?
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Have you ever had a hallucination or dream-like mental images when falling asleep?
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For how long?
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Have you ever experienced sudden physical weakness during strong emotions? (ie: legs going limp while laughing or when angry)
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For how long?
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Do you have difficulty staying awake to drive?
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For how long?
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Have you ever had an automobile accident due to sleepiness?
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Date of Accident
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PAST MEDICAL HISTORY
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Allergies - Please list
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Current or past medical condition (Please select all that apply)
• • •
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If other, specify
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MEDICATIONS - Name / Dose
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Over the counter medications
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Medication Allergies
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Are you currently using supplemental oxygen
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If yes, _____ LPM
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SOCIAL HISTORY
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Caffeine
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How many cans of caffeinated beverage do you consume? (Cola, Soda, etc.)
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How many cups of tea or coffee do you consume?
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Tobacco
• • •
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How many packs per day?
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How many years?
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Home
• • •
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How many children?
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Alcohol
• • •
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Illicit Drugs
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What are/were you using?
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Work
• • •
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Occupation?
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FAMILY HISTORY: Family History including father, mother, and siblings:
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Diabetes
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Person/People with disorder
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High B/P
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Person/People with disorder
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Stroke
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Person/People with disorder
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Narcolepsy
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Person/People with disorder
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Depression
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Person/People with disorder
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Obesity
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Person/People with disorder
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Snoring
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Person/People with disorder
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Sleep Apnea
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Person/People with disorder
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Daytime Fatigue
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Person/People with disorder
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Anxiety
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Person/People with disorder
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SYMPTOMS REVIEW: (please select Yes or No for each option below)
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Constitutional Review
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Fever
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Night Sweats
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Unexplained weight loss / gain
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Ear, Nose and Throat Review
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Hearing Loss
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Hoarseness
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Sore Throat
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Nasal Congestion
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Pulmonary Review
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Coughing
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Shortness of breath
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Difficulty breathing lying flat
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Difficulty breathing at night
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Wheezing
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Coughing up blood
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History of positive TB skin test
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Musculoskeletal Review
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Muscle aching
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Joint Pain
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Endocrine Review
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Excessive thirst
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Skin moistness or dryness
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Heat intolerance
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Cold intolerance
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Cardiac review
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Chest Pain
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Ankle Swelling
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Heart Murmur
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GI Review
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Blark Stools or bleeding from bowels
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Nausea/Vomiting
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Trouble Swallowing
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Abdominal Pain
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GU Review
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Prcquent bladder infections
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Painful urination
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Frequent urination
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Blood in urine
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Night time urination
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Loss of bladder control
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Difficulty starting stream of urine
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Skin Review
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Skin Rash
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Easy bruising
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Psychosocial / Social review
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Loss of appetite
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Feeling depressed
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Anxiety
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Agitation
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Increased stress/trouble at work
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Neurological Review
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Paralysis
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Numbness/Weakness in hands, feet or legs
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Trouble with balance
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History of stroke
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Difficulty with concentration
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Seizures
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Headaches
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Epworth Sleepiness Scale
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Other complaints not mentioned above
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The Epworth Sleepiness Scale
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Total item 1-17
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In a car while stopped for few mins in traffic
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Sitting quietly after lunch without alcohol
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Sitting and Talking to Someone
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Lying down to rest in the afternoon when you can
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As a passenger in a car for an hr and no break
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Sitting Inactive in a Public Place
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Watching TV
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Sitting and Reading
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