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EMORYSLEEPCENTERSleepandHealthQuestionnaire
Demographics Today’sDate:_____/_____/______Name:_____________________________________ DateofBirth:_____/_____/______Address:________________________________________________ Sex:Male☐ Female☐City/State/Zip:________________________________________________________PreferredContactNumber:________________________________________________Work☐Home☐Cell☐Occupation:________________________________________________Height:______ft______in Weight:______lbs ShirtCollarSize________inchesNameofdoctorwhoreferredyou:_____________________________________ Doctor’sPhoneNumber:_____________________________________Doctor’sAddress:_____________________________________ City/State/Zip:________________________________________________________ReasonforReferralWhatwouldyousayisyourprimarysleepproblem?(Ifnone,whydidyourdoctorreferyoutothesleepclinic?)
Describehowandwhenthisproblembegan,andhowoftenitisoccurring.
Haveyoueverhadasleepstudy?Yes☐ No☐Ifyes,whenandwhere:________________________________________________________________________________________Describeanytreatmentsyouhavereceivedforyourproblem:____________________________________________________________________________________________________________
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YourSleepHabitsHowmanyhoursofsleepdoyouusuallygetpernight? Whattimedoyouusuallygotobed? Whattimedoyouusuallywakeup? Howlongdoesittakeforyoutofallasleep? Howmanytimesdoyoutypicallywakeupatnight? Whatawakensyou? Ifyouwakeup,onaverage,doyouhavetroublegoingbacktosleep?
Whathoursdoyouwork? Doyoueverrotateshifts?
SymptomsDuringSleep Yes NoDoyoufeelrefreshedafteratypicalnight’ssleep? ☐ ☐Doyoufeelsleepyduringthedayevenwhenyouhavesleptallnight? ☐ ☐Doyounapatleastonceperweek? ☐ ☐Doyoufeelrefreshedafterashortnap? ☐ ☐Doyousleepbetterinareclinerorachairthanyoudoinbed? ☐ ☐Doyoueverexperiencevividdream-likescenesuponawakeningorfallingasleep? ☐ ☐Whenyouareangryorlaugh,doyoueverfeelweakinanypartofyourbody? ☐ ☐Areyoueverunabletomoveorspeakforashortperiodoftimeasyouarefallingasleeporawakening?
☐ ☐
Doyouhaveacreepingorcrawlingsensationinyourlegswhenyouliedowntosleep? ☐ ☐Doyousnore? ☐ ☐Isyourbedpartnerdisturbedbyyoursnoring? ☐ ☐Hasanyoneeverytoldyouthatyourbreathingstopsforbriefperiodsduringthenight? ☐ ☐Doyouhaveabittertasteinthebackofyourthroatwhenyouwakeup? ☐ ☐Doyouwalkortalkinyoursleep? ☐ ☐Doyougrindorclenchyourteethduringyoursleep? ☐ ☐Areyouarestlesssleeper,tossingandturningatnight? ☐ ☐Doyoufeeldrowsywhiledrivingyourcar? ☐ ☐Haveyoueverfallenasleepwhiledriving? ☐ ☐
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Indicate,onaverage,howoftenyouexperiencethefollowingsymptomswhensleepingortryingtosleep.
Symptom TimesPerWeek Daily 4-6 1-3 NeverMymindraceswithmanythoughtswhenItrytofallasleep ☐ ☐ ☐ ☐IoftenworrywhetherornotIwillbeabletofallasleep ☐ ☐ ☐ ☐Fatigue ☐ ☐ ☐ ☐Awakenwithadrymouth ☐ ☐ ☐ ☐Morningheadaches ☐ ☐ ☐ ☐Irritability/Depression ☐ ☐ ☐ ☐Memoryimpairment/Inabilitytoconcentrate ☐ ☐ ☐ ☐Sinustrouble,nasalcongestionorpost-nasaldripinterferingwithsleep
☐ ☐ ☐ ☐
Heartburn,sourbelches,regurgitation,orindigestionwhichdisruptssleep
☐ ☐ ☐ ☐
Painwhichdelays,prevents,orawakensmefromsleep ☐ ☐ ☐ ☐Irresistibleurgestomovemylegsorarmswhileinbed ☐ ☐ ☐ ☐Creepingorcrawlingsensationsinyourlegsbeforefallingasleep
☐ ☐ ☐ ☐
Legsorarmsjerkingduringsleep ☐ ☐ ☐ ☐Frequenturinationdisruptingsleep ☐ ☐ ☐ ☐SleeptalkingorSleepwalking ☐ ☐ ☐ ☐Snoring ☐ ☐ ☐ ☐
EpworthSleepinessScaleThisreferstoyourusualwayoflifeinrecenttimes.Evenifyouhavenotdonesomeofthesethingsrecently,trytoworkouthowtheywouldhaveaffectedyou.Usethefollowingscaletochoosethemostappropriatenumberforeachsituation:0=Wouldneverdoze1=Slightchanceofdozing2=Moderatechanceofdozing3=Highchanceofdozing
Situation ChanceofDozingSittingandreading Watchingtv Sitting,inactiveinapublicplace(eg,atheatreormeetingplace) Asapassengerinacarforanhourwithoutabreak Lyingdowntorestintheafternoonwhencircumstancespermit Sittingandtalkingtosomeone Sittingquietlyafteralunchwithoutalcohol Inacar,whilestoppedforafewminutesintraffic
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MedicalHistoryPleasecheckallpreviouslydiagnosedmedicalconditions:☐ HighBloodPressure ☐ Diabetes ☐ Reflux/Heartburn☐ Highcholesterol ☐ Asthma ☐ Stroke☐ Atrialfibrillation(AFib) ☐ Congestiveheartfailure/Heartfailure☐ DepressionPleaselistanyothersignificantmedicalproblemsandanysurgeriesyouhavehad:
CurrentMedications,prescriptionsandotherwise(withdosesifknown)
FamilyMedicalHistory Age MedicalProblems,(ifdeceased,listcauseofdeath)
Mother Father Brother(s)
Sister(s)
Children
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SocialHistoryDoyoucurrentlysmoke? ☐ Yes ☐ NoPacksperday:______ Howmanyyearshaveyousmoked:______Ifnotcurrentlysmoking,haveyousmokedinthepast? ☐ Yes ☐ No
Whenwasyourlastcigarette?______Numberofalcoholicbeveragesperday:______/perweek:______/permonth:______Howmuchcaffeinatedcoffeedoyoudrinkperday?______cupsHowmuchcaffeinatedtea(hotoriced)doyoudrinkperday?______cups/______glassesHowmuchcaffeinatedsodatoyoudrinkperday?______cansReviewofSystems(pleaseanswerallquestions,checkingyesorno)
Yes No General Comment☐ ☐ Weakness
☐ ☐ Fatigue
☐ ☐ Decreasedappetite
☐ ☐ Increasedappetite
☐ ☐ Weightloss
☐ ☐ Weightgain
☐ ☐ Chills
☐ ☐ Fever
☐ ☐ Nightsweats
Yes No Eyes,Ears,Nose,Throat Comment☐ ☐ Decreasedabilitytosee
☐ ☐ Blurredvision
☐ ☐ Spotsbeforeeyes
☐ ☐ Difficultyhearing
☐ ☐ Ringinginears
☐ ☐ Paininears
☐ ☐ Dischargefromear
☐ ☐ Nosebleeds
☐ ☐ Nasalcongestion
☐ ☐ Post-nasaldrip
☐ ☐ Sinustrouble
☐ ☐ Sorethroat
☐ ☐ Hoarseness
☐ ☐ Paininneck
☐ ☐ Dentaltrouble
☐ ☐ Bleedinggums
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Yes No Respirator Comment☐ ☐ Cough
☐ ☐ Coughupphlegm
☐ ☐ Coughingupblood
☐ ☐ Wheezing
☐ ☐ Asthma
☐ ☐ COPD
☐ ☐ Shortnessofbreath
☐ ☐ Chestpainwithcoughordeepbreathing
Yes No Cardiovascular Comment☐ ☐ Chestdiscomfort
☐ ☐ Shortnessofbreathwhenlyingdown
☐ ☐ Sittinguptobreathe
☐ ☐ Heartracing
☐ ☐ Swellingoflegs
☐ ☐ Varicoseveins
☐ ☐ Legpainwithexertion
☐ ☐ Blue/purplecolorofhands/feet
Yes No Gastrointestinal Comment☐ ☐ Nausea
☐ ☐ Vomiting
☐ ☐ Diarrhea
☐ ☐ Constipation
☐ ☐ Heartburn
☐ ☐ Abdominalpain
☐ ☐ Brightredbloodinstools
☐ ☐ Blackstools
☐ ☐ Changeinbowelhabits
☐ ☐ Hemorrhoids
Yes No Musculoskeletal Comment☐ ☐ Painfuljoints
☐ ☐ Swellingofjoints
☐ ☐ Rednessofjoints
☐ ☐ Stiffnessofjoints
☐ ☐ Deformitiesofjointsorextremities
☐ ☐ Musclepain
☐ ☐ Backpain
☐ ☐ Painrunningdownthebackofyourlegs
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Yes No Endocrine Comment☐ ☐ Goiter
☐ ☐ Heatintolerance
☐ ☐ Coldintolerance
☐ ☐ Tremuloushands
☐ ☐ Changeinpitchofvoice
☐ ☐ Increasedbodyhair(face,underarmsorpubic)
☐ ☐ Decreasedbodyhair
☐ ☐ Lossofperiods
☐ ☐ Increasedthirst
☐ ☐ Increasedurination
Yes No Neurologic/Psychiatric Comment☐ ☐ Nervousness/Anxiety
☐ ☐ Depression
☐ ☐ Difficultywithmemoryforpastevents
☐ ☐ Difficultywithmemoryforrecentevents
☐ ☐ Difficultywiththinkingorproblemsolving
☐ ☐ Headaches
☐ ☐ Blackouts
☐ ☐ Dizziness
☐ ☐ Doublevision
☐ ☐ Paralysisorweaknessinlimb(s)
☐ ☐ Lossofsensation
☐ ☐ Lossofbalance
☐ ☐ Lossofcoordination
☐ ☐ Difficultyinspeaking
☐ ☐ Seizuresorspells
Yes No Hematologic/Allergy Comment☐ ☐ Anemia
☐ ☐ Blooddisorder
☐ ☐ Immunocompromised
☐ ☐ Seasonalallergies
☐ ☐ Drugallergies
Yes No Skin Comment☐ ☐ Itching
☐ ☐ Rashorulcers
☐ ☐ Changeincolor
☐ ☐ Changeintextureofhairorhairloss
☐ ☐ Nailchanges