Jameel Durrani, MD FCCP FAASM 327 main Street, Suite 2 Emmaus, PA 18049

Phone 610-966-9667 | Fax 610-966-9660Sleep Medicine History Form

Yes Don't KnowNoDo you snore?If yes, is it affecting your cohabitation (spouse complaints)? NoYes

Are you a restless sleeper?

NoYesNoYes

NoYes Shift worker?NightDay MixedIf Yes, which shift?

NoYes

NoYesNoYes

If checked, please tell us about your sleep patternsCheck here if you sleep and wake up at odd times.

How much time does it take you to fall asleep?

How many times?

Weekdays: Time to bed?

How many of coffee, caffeine, soda do you drink daily?

Wake up at?Weekends: Time to bed?

DAYTIME NAPSDur.?

Wake up at?

Pets in bedroom?TV in bedroom?

Find out now if your daytime sleepiness is excessive.It's easy. The Epworth Sleepiness Scale (ESS) has 8 routine daytime situations that you can rate on a scale of 0 - 3 based on your likelihood of dozing off or falling asleep in each situation. Circle the applicable #

NoYes

Do you routinely wake up at night? NoYes

Difficulty falling back to sleep:

NoYesNoYesVisible clock in bedroom

0 = Would never doze1 = Slight chance of dozing

1 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 3

Sitting and reading

As a passenger in a car for an hour with no breakLying down to rest in the afternoonSitting and talking to someoneSitting quietly after lunch without alcoholIn a car while stopped for a few min. in traffic

Sitting inactive in a public place (theater/mtg.)Watching TV

Situation Chance of Dozing

NoYes

BEDROOM ENVIRONMENT

THE EPWORTH SLEEPINESS SCALE

PATIENT INFORMATION

SLEEP SYMPTOMS SLEEP TIMINGS

Feel better after the nap?Do you take daytime naps?

Do you feel tired or fatigued during the daytime?Dose off watching TV, or reading a book?Fight off drowsiness while driving?Any near misses or accidents?

Did you ever drive to a place, and have no recall of how you got there?In emotional situations (angry/laughing out loud) do you feel any weakness in your legs or actually fall down?Do you often forget what you were doing in the middle of something (ie Enter a room, and forget why you are there)?

NoYesNoYes

DAYTIME WAKEFULNESS

Date of Birth Last Name MI First Name

Have you ever had a sleep study before?

Are you currently using CPAP on a nightly basis? : Current CPAP pressure? :

Yes No

Yes No Sometimes

If Yes, when? Where?

Cm.

NoYesNoYesNoYes

Do you frequently drop things(ordinary objects like glass, files, keys etc)? NoYes

OTHER DAYTIME SYMPTOMS

Do you often notice any cramps, creeping or crawling sensations in your legs in the evening or when you go to bed?If Yes, do these sensations get better if you take a walk, or stretch your legs?If Yes, do these sensations make it difficult to sleep?

EVENING SYMPTOMS

DREAM HISTORY

Has anybody noticed you to have pauses in your breathing?Has anybody noticed you choking/grunting while asleep?Do you usually have have dry mouth on waking up in AM? Do you usually have have headache on waking up in AM

2 = Moderate chance of dozing3 = High chance of dozing

NoYesDo all dreams have the similar content?

NoYesDo you recall your dream content?Do your dreams mix with wakefulness?

Do you find yourself acting out your dreams at times?, (ie jumping out of bed, punching the wall, etc):

NoYesDo you feel you dream excessively?

Yes No

Yes NoNoYes

Yes No

Yes No

Is there anything else you would like your physician to know about your sleep pattern?

Date

GENERAL SLEEP TIMINGS

Yes No

NoYes

NoYes

NoYes