Name of Patient:   

Your Relationship to the Patient:


How often have you observed this person's sleep?
Never  Once or twice  Every night  Often

Has this person fallen asleep during normal daytime activities or in dangerous situations? If yes, explain:



What behaviors have you observed in this person while he or she was asleep?
Loud snoring Awakening with pain Sitting up in bed
Light snoring Limb movement every 10-20 seconds Teeth grinding
Occasional loud snorts Leg or arm twitching Head rocking/banging
Choking Leg kicking Sleepwalking
Pauses in breathing Shaking or rocking Bedwetting
Doing an unusual activity   Becoming very rigid

OTHER:

Please describe the checked behaviors in more detail. Include a description of the behavior, when it occurs during the night, frequency during the night, and how often it occurs (every night, 4 times a week, etc.).

Print This Document 

Click here to print this Document (this will bring out the print dialog box)

If that link doesn't work click on 'File/Print...'

Bring the printed document with you to your Sleep-Wake Disorders Center of South Florida appointment.