Patient Questionnaire
This pre-visit questionnaire is lengthy, but it is important that you complete it as best you can. Most of the questions include a dropdown box for easy selection or require just a yes or no answer.
Date
 -
Month
 -
Day
Year
Date
Medical Record Number
General Information
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Gender
*
Please Select
M
F
Weight
Height in Inches
BMI
How long have you had trouble sleeping?
*
Days
Months
Years
Have you been diagnosed with sleep apnea?
*
Yes
No
If so, when/where?
*
Have you used a CPAP machine for sleep apnea before?
*
Yes
No
If so, last known pressure setting:
*
Insomnia
Do you have trouble falling asleep (lay awake for half an hour or more)?
*
Yes
No
Do you have trouble staying asleep once you fall asleep?
*
Yes
No
Do you wake up earlier in the morning than you would like to?
*
Yes
No
Do you feel like you don't get enough sleep?
*
Yes
No
What is preventing you from a good night's sleep (choose all that apply):
*
Noise
Pain
Medication
Shift work
Worries
Restless leg
Cough
Difficulty breathing
Acid reflux
Thoughts racing through your mind
Sleep habit/hygiene (choose all that apply):
*
You have a clock in your bedroom
You watch TV in your bedroom
You take naps during the day
You keep the lights on in the bedroom when you sleep
You drink caffeine after dinner
You are a shift worker
At what time do you usually go to bed on weekdays?
*
Hour Minutes
AM
PM
AM/PM Option
At what time do you usually go to bed on weekends?
*
Hour Minutes
AM
PM
AM/PM Option
At what time do you usually wake up on weekdays?
*
Hour Minutes
AM
PM
AM/PM Option
At what time do you usually wake up on weekends?
*
Hour Minutes
AM
PM
AM/PM Option
How many hours do you feel is your ideal amount of sleep per day?
*
What is the average number of hours of sleep you had per day during the last week?
*
Excessive Daytime Sleepiness/Hypersomnia
Do you feel sleepy and tired most of the day?
*
Yes
No
Do you feel fatigued, exhausted, tired, or not up to par nearly every day?
*
Yes
No
Do you feel that your sleep is not refreshing or restful?
*
Yes
No
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep during the following situations? 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading
*
0
1
2
3
Watching TV
*
0
1
2
3
Sitting inactive in a public place (theater or meeting)
*
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
*
0
1
2
3
Sitting and talking to someone
*
0
1
2
3
Sitting in a car while stopped for a few minutes in traffic
*
0
1
2
3
Your total score from answers to Epworth Sleepiness Scale questions above:
*
Restless Leg/Periodic Limb Movement Disorder
Do you experience a creeping, crawling, or aching feeling in your legs when you try to sleep?
*
Yes
No
Do you have an urge to move your legs at night and can't keep still?
*
Yes
No
Do you or have you been told that you kick or jerk during your sleep?
*
Yes
No
Sleep Disordered Breathing
Do you snore or have you been told that you snore very loud at night?
*
Yes
No
Is your snoring loud enough to bother your bed partner/other people in the household?
*
Yes
No
Have you been told that you hold your breath while sleeping?
*
Yes
No
Did you have a feeling of choking or suffocation during sleep?
*
Yes
No
Do you wake yourself up snoring?
*
Yes
No
Do you have dry mouth when you wake up?
*
Yes
No
Do you have a headache when you wake up?
*
Yes
No
Do you have periods of the day when you feel dazed and have trouble paying attention, remembering things, or staying awake?
*
Yes
No
Narcolepsy
Do you have vivid dreams when you just fall asleep or just wake up?
*
Yes
No
Do you have vivid dreams when you have daytime naps?
*
Yes
No
Do you often feel that you are unable to move (paralyzed) when you are waking up?
*
Yes
No
Do you get a sudden weakness (brief periods of paralysis or being unable to move) when you are laughing, angry, or in a situation of strong emotion?
*
Yes
No
Parasomnias
Do you wake up at night with confusion and can't remember a thing in the morning?
*
Yes
No
Do you sleepwalk?
*
Yes
No
Do you wake up screaming loudly and crying?
*
Yes
No
Do you experience head banging or body rocking during sleep?
*
Yes
No
Do you experience arm, leg, or head jerks as you fall asleep?
*
Yes
No
Do you talk in your sleep?
*
Yes
No
Do you have painful cramps in the calf or in the foot?
*
Yes
No
Do you have nightmares?
*
Yes
No
Do you experience acting up dreams, talking, laughing, yelling, punching, screaming, leaping, or running out of bed?
*
Yes
No
Do you grind or clench your teeth during sleep?
*
Yes
No
Do you experience bedwetting?
*
Yes
No
Do you have repeated movements of legs in the same pattern during sleep?
*
Yes
No
Associated Medical Conditions
Do you have any of the following medical conditions (choose all that apply)?
*
High blood pressure (hypertension)
Heart attach (myocardial infarction)
Heart pain (angina)
Heart failure (CHF)
Stroke (CVA)
Mini-stroke (TIA)
Sinus congestion or obstruction
Depression
Asthma
Emphysema (COPD)
Hypoactive thyroid (hypothyroidism)
Motor vehicle accident related to sleep condition
Consent
*
I agree to allow staff at LRH Sleep Disorders Center to contact me.
Phone Number
*
E-mail
*
example@example.com
Submit
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