Patient Questionnaire

  • 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
     - -

  • General Information

  • Date of Birth*
     - -
  • How long have you had trouble sleeping?*
  • Have you been diagnosed with sleep apnea?*
  • Have you used a CPAP machine for sleep apnea before?*

  • Insomnia

  • Do you have trouble falling asleep (lay awake for half an hour or more)?*
  • Do you have trouble staying asleep once you fall asleep?*
  • Do you wake up earlier in the morning than you would like to?*
  • Do you feel like you don't get enough sleep?*
  • What is preventing you from a good night's sleep (choose all that apply):*
  • Sleep habit/hygiene (choose all that apply):*

  • Excessive Daytime Sleepiness/Hypersomnia

  • Do you feel sleepy and tired most of the day?*
  • Do you feel fatigued, exhausted, tired, or not up to par nearly every day?*
  • Do you feel that your sleep is not refreshing or restful?*

  • 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*
  • Watching TV*
  • Sitting inactive in a public place (theater or meeting)*
  • Lying down to rest in the afternoon when circumstances permit*
  • Sitting and talking to someone*
  • Sitting in a car while stopped for a few minutes in traffic*

  • Restless Leg/Periodic Limb Movement Disorder

  • Do you experience a creeping, crawling, or aching feeling in your legs when you try to sleep?*
  • Do you have an urge to move your legs at night and can't keep still?*
  • Do you or have you been told that you kick or jerk during your sleep?*

  • Sleep Disordered Breathing

  • Do you snore or have you been told that you snore very loud at night?*
  • Is your snoring loud enough to bother your bed partner/other people in the household?*
  • Have you been told that you hold your breath while sleeping?*
  • Did you have a feeling of choking or suffocation during sleep?*
  • Do you wake yourself up snoring?*
  • Do you have dry mouth when you wake up?*
  • Do you have a headache when you wake up?*
  • Do you have periods of the day when you feel dazed and have trouble paying attention, remembering things, or staying awake?*

  • Narcolepsy

  • Do you have vivid dreams when you just fall asleep or just wake up?*
  • Do you have vivid dreams when you have daytime naps?*
  • Do you often feel that you are unable to move (paralyzed) when you are waking up?*
  • 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?*

  • Parasomnias

  • Do you wake up at night with confusion and can't remember a thing in the morning?*
  • Do you sleepwalk?*
  • Do you wake up screaming loudly and crying?*
  • Do you experience head banging or body rocking during sleep?*
  • Do you experience arm, leg, or head jerks as you fall asleep?*
  • Do you talk in your sleep?*
  • Do you have painful cramps in the calf or in the foot?*
  • Do you have nightmares?*
  • Do you experience acting up dreams, talking, laughing, yelling, punching, screaming, leaping, or running out of bed?*
  • Do you grind or clench your teeth during sleep?*
  • Do you experience bedwetting?*
  • Do you have repeated movements of legs in the same pattern during sleep?*

  • Associated Medical Conditions

  • Do you have any of the following medical conditions (choose all that apply)?*
  • Format: (000) 000-0000.
  • Should be Empty: