Name:    Date of Birth:


Chief Complaint:

History:
1. Do you snore?
    Does your snoring disturb your partner?
    Does your snoring disturb others in the next room
    Is your snoring becoming progressively worse?
    Do you snore when you are on your back?
    Do you snore in all positions?
    Have you been told that you stop breathing for periods between snores?
    Has your snoring caused you to wake up suddenly?
    Has your bed partner ever left the room to sleep elsewhere because you were snoring?
    Has your snoring caused you social embarrassment on vacation; conferences; motels?
2. Do you awaken from sleep tired, no matter how long you sleep?
3. Are you excessively tired during the day no matter how much you got the night
    before?
    Do you fall asleep driving or at stop lights?
    Do you fall asleep watching television?
    Does daytime tiredness interfere with your school or work or relationships with other people?
    Do your friends or family say you are often grumpy and irritable
    Do you sweat excessively at night?
4. Do you awaken with headaches?
5. Have you had trouble with memory?
6. Do you have trouble concentrating?
7. Do you nap: If so, are the naps refreshing or do you awaken from naps still tired?
8. Have you noticed your hearth pounding or beating irregularly during the night?
9. Do you feel like you have too little energy?
10. Do you seem to be losing your sex drive?
    Males: Do you have trouble getting an erection?
11. Do you often feel sad or depressed?
12. Do you feel unusually anxious?
13. Do you or have you in the past smoked cigarettes?
14. Do you have any of the following?
15. Do you have indigestion of heartburn?
16. Do you awaken at night or in the morning with an acid or sour taste in your mouth?
17. Do you have a history of:  
    Heart Disease?
    Hypertension?
    Diabetes Mellitus?
    Seizure Disorder?
    Underactive thyroid?
    Neuromuscular Disease?
18. Do you dream?
19. Have you or other people noticed that parts of your body jerk during sleep?
20. Have you been told that you kick at night?
21. When trying to go to sleep do you experience an aching or crawling sensation in you
     legs?
22. Do you have trouble keeping your legs still at night, feeling the need to move them
     to feel comfortable?
23. Do you awaken with sore or aching muscles?
24. Do you have a family history of sleep disorders?
25. Do you have a history of sleep walking or sleep talking?
26. Do you consume alcohol daily?
    If so, how much?  
27. Do you have chronic pain?
28. Do you experience vivid dreamlike scenes upon falling asleep or awakening?
29. Do you feel like you are hallucinating when you fall asleep?
30. Do you dream soon after falling asleep?
    During naps?
31. Do you have "sleep attacks" during the day no matter how hard you try to stay
     awake?
32. Do you have episodes of feeling paralyzed during sleep?
    When you awaken from a deep sleep?
33. Do strong emotions cause you to become weak in the muscles?
34. What was your approximate weight at age 21?  
35. How many hours of sleep did you previously require to feel refreshed the next day?
     		 
36. Do you have difficulty initiating sleep?
37. Do you have difficulty maintaining sleep?
38. Do you awaken earlier in the morning than you would like to?

39. Describe your sleep-wake schedule:

40. List of medications:

41. List of drug allergies:

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