Sleep Questionnaire

Sleep Questionnaire
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Center for Sleep Disorders at
Johnson City Medical Center
Sleep Disorders Lab at
Indian Path Medical Center
Sleep Disorders Lab at
Sycamore Shoals Hospital
Sleep Questionnaire
Name:_____________________________________________________ Date:_______________
Address:________________________________________________________________________
Day Time Phone:__________________________ Night Time Phone_______________________
Birth Date:_________________ SS#:_______________ Height:_________ Weight:__________
Primary Doctor:________________________________________ Phone No._________________
Referring Doctor:_______________________________________ Phone No._________________
Reason for Referral for Sleep Study:___________________________________________________
Please answer the following questions about your sleep habits in recent weeks:
1. Do you snore Never___ Rarely____ Occasionally___ Frequently___
(N=No Y=Yes)
Who told you that you snore______________________________________________________________
2. How many years have you snored____________ Has your snoring worsened recently N___ Y___
3. Has anyone told you that you stop breathing during your sleep N___ Y___ Who___________________
4. (Check all that apply) When sleeping do you snort:____ gasp:____ wake up choking:____ or smothering:____
5. Do you have difficulty breathing through your nose Never___ Rarely___ Occasionally___ Frequently___
6. Are you a mouth breather Never___ Rarely___ Occasionally___ Frequently___
7. What time do you usually go to bed during the week_________________ on weekends_______________
8. How long does it take you to fall asleep (give a range if needed) __________ minutes to __________ hours
9. Do you wake up during the night N___ Y___ How many times_____________________________
10. Why do you wake up during the night (pain, bathroom, worry, etc)________________________________
11. What time do you usually wake up during the week_________________ on weekends________________
12. How long does it take you to get out of bed in the morning_______________________________________
13. Is your regular sleep refreshing Never___ Rarely___ Occasionally___ Frequently___
14. Do you awaken with headaches Never___ Rarely___ Occasionally___ Frequently___
15. Do you take naps during the week N___ Y___ If yes, how often_________________________________
16. Are your naps refreshing Never___ Rarely___ Occasionally___ Frequently___
17. Do you ever have vivid dreams, even though you are not totally asleep
Never___ Rarely___ Occasionally___ Frequently___

Sleep Questionnaire
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If yes, explain_________________________________________________
18. Do you ever experience waking or falling asleep but being unable to move as if paralyzed
Never___ Rarely___ Occasionally___ Frequently___
If yes, explain___________________________________________________________________________
19. Do you ever have marked muscle weakness when excited (laughing, angry)
Never___ Rarely___ Occasionally___ Frequently___
If yes, explain_______________________________________________________________
20. Do you ever have strange sensations in your legs or do you need to get out of bed to walk before falling
asleep Never___ Rarely___ Occasionally___ Frequently___
21. Do you toss and turn during the night Never___ Rarely___ Occasionally___ Frequently___
22. Are your covers tangled in the morning Never___ Rarely___ Occasionally___ Frequently___
23. Do you currently sleepwalk Never___ Rarely___ Occasionally___ Frequently___
24. Do you currently talk in your sleep Never___ Rarely___ Occasionally___ Frequently___
25. Do you currently grind your teeth while sleeping Never___ Rarely___ Occasionally___ Frequently___
26. Do you dream Never___ Rarely___ Occasionally___ Frequently___
27. Do you drink any of the following:
(Circle those that apply): caffeinated coffee caffeinated tea caffeinated soda
If yes, how often________________________________________________________________________
28. Do you drink alcohol Never___ Rarely___ Occasionally___ Frequently___ How much per day________
29. Do you now or have you ever smoked N___ Y___
If so, when and how often:_________________________________________________________________
30. What is your occupation__________________________________________________________________
31. What hours do you usually work ______ to ______ Do you work rotating shifts N___ Y___
32. Does anyone in your family have sleep problems N___ Y___
If yes, explain:__________________________________________________________________________
33. How likely are you to doze off or fall asleep in the following situations
0 = Never 1 = Slight chance 2 = Moderate chance 3 = High chance
Situation
Chance of Dozing
Sitting and reading............................................................................................. ________________
Watching TV ..................................................................................................... ________________
Sitting inactive in a public place (theater, meeting, etc) ................................... ________________
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 to someone .......................................................................... ________________
Sitting quietly after lunch without alcohol ........................................................ ________________
In a car, while stopped for a few minutes in traffic........................................... ________________

Sleep Questionnaire
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34. Do you feel your sleepiness is a result of poor quality sleep N____ Y____
35. Do you feel excessively sleepy during the day N____ Y____
36. Have you ever been told you make unusual movements such as talking, swinging arms about, acting out
dreams, etc. during sleep N____ Y____
If yes, explain:__________________________________________________________________________
37. Have you ever caused injury to yourself or others when you were asleep Y____ N____
If yes, explain:__________________________________________________________________________
38. Are you allergic to any medications N___ Y___ List:__________________________________________
_______________________________________________________________________________________
39. Have you ever taken any prescription or over the counter medications for sleep N___ Y___
List:___________________________________________________________________________________
40. Were any of these medications effective N___ Y___ List:_______________________________________
41. Have you had any overnight stays in the hospital N___ Y___ If yes please complete:
______________________________________________________________ ________________________
Reason for hospital stay
When (approximately)
______________________________________________________________ ________________________
Reason for hospital stay
When (approximately)
______________________________________________________________ ________________________
Reason for hospital stay
When (approximately)
______________________________________________________________ ________________________
Reason for hospital stay
When (approximately)
42. List all medications that you are taking and when taken (Ex: every morning, 3 times/day, at bedtime, when
needed for headache, etc.) Use back of form if necessary.
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
43. List current medical conditions (stroke, heart disease, etc.) Use back of form if necessary.
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
44. If you should need CPAP supplies, do you have a preference of a medical equipment company
_________________________________________________________________________________________