SLEEP HISTORY QUESTIONNAIRE
Please check all sleep concerns that bring you here today
Last Name
First name
Height
Weight
Age
Date of Birth
Wake up gasping, choking or can't breathe
Yes
No
Daytime Sleepiness
Yes
No
Unusual behaviors during sleep
Yes
No
Pain interfering with sleep
Yes
No
Sudden loss of muscle tone triggered by emotions (i.e. laughing)
Yes
No
Sleep eating
Yes
No
Act out dreams
Yes
No
see things as I fall asleep/wake up
Yes
No
Inability to move when going to sleep or waking up
Yes
No
Nightmares
Yes
No
Past/Current Medical History: Have you been diagnosed with or had any of the following? Click all that apply
Hypertension
Coronary Artery Disease
Thyroid Disease
Stroke
Asthma/ COPD
Atrial Fibrillation
Congestive Heart Failure
High Cholesterol
List of Medications: Include dosage if known
Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations? 0=no chance 1=slight chance 2=moderate chance 3= high chance
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place (e.g. theater/meeting)
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Lying down to rest in the afternoon
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch (with no alcohol)
0
1
2
3
In a car, while stopped in traffic
0
1
2
3
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