Name:   Date:

Home Phone: ( ) - -  Work Phone: ( ) - -

Social Security# - -  Gender: M F   DOB:

Height:   Weight:  Neck Size:   Age:  Race:

 

Primary Physician:   Phone: ( ) - -

Refering Physician:  Phone: ( ) - -

Insurance's Name:   ID#

Briefly describe your sleep problem:

Current medications include over-the-counter medicines and dosage information:

Have you ever been diagnosed with Sleep Apnea?   Yes   No

Prescribed or attempted treatments:

Do you snore? Loud

Moderate   Mild  Laying on my back  Never

Can you breathe through your nose?

Yes   No

Both nostrils?
Yes   No

Do you awaken with dry mouth or sore throat?

Yes     No   Sometimes

Do you awaken gasping for air or short of breath?

Yes   No   Sometimes

Has anyone ever witnessed you stop breathing at night?

Yes   No

Do you awaken with morning headaches?

Yes   No   Sometimes

Have you been diagnosed with Emphysema or COPD?

Yes   No

Do you have a history of Heart Failure or Heart Attach?

Yes   No

Do you have a history of High Blood Pressure?

Yes   No

Have you been diagnosed with any muscular weakness disorder?

Yes   No

Do you kick or twitch your legs at night, prior to falling asleep?

Yes   No

Do you have trouble keeping your legs still at night when relaxed?

Yes   No

Do you get achy or “creeping? Sensations in your legs at night?

Yes   No

When angry, surprised, or laughing: have you felt liked you were going to faint, blackout or fall down?

Yes   No

Have you had difficulty staying awake during the day since you were a teenager?

Yes   No

Do you experience vivid, life-like scenes (dreamish) when you are very tired, or prior to falling asleep?

Yes   No

Have you awakened from sleep, and been unable to move?

Yes   No

Have you been told you grind your teeth while asleep?

Yes   No

Do you sweat at night while asleep, even without being hot?

Yes   No

Polio, Myopathy, Myasthenia Gravis?

What is your normal bedtime?

What is your normal wake time?


Epworth Sleepiness Scale:

How likely are you to fall asleep/doze during the circumstances listed below?

The questions refer to recent life. If you have not reacted to some of these, estimate how you feel you might have reacted.

0 = No Chance   1 = Slight Chance   2 = Moderate Chance   3 = High Chance
Chance of Dozing Situation
Sitting and Reading
Watching TV
Sitting inactive in a public place (Theatre or Meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking with someone
Sitting quietly after lunch, without alcohol
Driving a car or while stopped in traffic


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