New Sleep Patient

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SLEEP QUESTIONARE

It is important for you to be as accurate as possible in answering the following questions. The purpose of this questionnaire is to get a total picture of your background and the nature of your present problem. Please complete these questions as thoroughly as you can



Describe your main problem(s) in your own words, including when and how this began and what treatment you have received for this in the past:

SLEEP HISTORY

Do you experience any of the following at night?
Do you have feelings of depression/anxiety?
Do you have feelings of anxiety or racing thought?
Do you have hallucinations upon falling asleep or upon waking?
Do you have crawling sensations in your legs?
Do you work split shifts or variable shifts?
Do you usually drink caffeine within two hours of going to bed?
Awaken from sleep short of breath or gasping for air
Experience crawling and aching feelings in your legs
Have you been told you snore at night?
Sweat excessively at night
Notice your heart pounding or beating irregularly during the night
Fall asleep during the day
Fall asleep involuntarily or while driving
Fall asleep or lose muscle tone when laughing or crying
Feel unable to move (paralyzed) when waking or falling asleep
Experience vivid dreamlike scenes upon awakening or falling asleep
Remember your dreams
Do any of your family members have sleep apnea?

Epworth Sleepiness Scale


How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired. This refers to your usual way of life in recent times. Even if you have not done some of these activities recently, try to work out how they would affect you.


Use the following scale to choose the most appropriate number for each situation.



0 = would never doze
1= slight chance of dozing
2= moderate chance of dozing
3= high chance of dozing

Situation

Chance of Dozing

Sitting and reading
Watching TV
Sitting, inactive in a public place (theatre, meeting, etc)
As a passenger in a car for an hour without break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
$0.00