Sleep History Questionnaire
Name ________________________________________ Today’s Date _______________
Birth date ___________ Gender: Male/Female Age_______ Ht_______ Wt ________
Referring physician _________________________________________________________
Primary Care physician ______________________________________________________
Briefly describe your sleep problem:
Where you feel it is necessary, please explain your yes answers.
Section 1: Sleepiness
Do you snore ? No Yes Don’t know
If you snore is it: Mild Moderate Loud Very loud
Does your snoring bother other people? No Yes I live alone
Has anyone noticed that you quit breathing during your sleep? No Yes____________
Is your sleep refreshing? No Yes ______________
What is your level of alertness in the morning? Poor Average Excellent
Do you usually wake up with a headache? No Yes________________
Do you feel excessively sleepy in the daytime? No Yes________________
How severe? Mild Moderate Severe
How do you feel in the day? Exhausted Good Great
Do you get sleepy while driving? No Yes_________________
Have you had accidents or near accidents due to sleepiness? No Yes_________________
Is the sleepiness affecting your work? No Yes_________________
Is the sleepiness affecting your social life? No Yes__________________
How recent is the sleepiness problem? ___________________________________________
Section 2: Sleep/Wake Habits
What is your usual bedtime? Work days________ Days off____________
What time do you awaken on Work days________ Days off____________
Do you work an unusual schedule? If so, what? _________________________________
Do you ever wake up gasping? No Yes How often? _______________
Why? - Nightmares? Acid in throat? Panic attacks? Short of breath? Other?
_________________________________________________________________________
Do you dream regularly? No Yes _________________
Do you have severe nightmares? No Yes _________________
Have you awakened screaming but were not awake? No Yes _________________
Do you usually prop up on pillows? No Yes _________________
If yes – how many pillows and why? _______________________________________
Do you sleep elsewhere than a bed? No Yes
If yes – where and why__________________________________________________
How many times do you awaken at night? ________________________________________
Reason: Brief awakening Bathroom Snacking Change Beds
Thinking Pain Other Disturbance in the bedroom (spouse, pet, child)
If a disturbance or other, explain__________________________________________
Do you have insomnia? No Yes_________________
Explain____________________________________________________
What sleep aids have you tried? ________________________________
Is the bedroom quiet? No Yes _________________
Do you nap in the daytime? No Yes
How often? __________ How long? _________ Is it refreshing? _________
Section 3: Sleep/Wake Pathology
When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? No Yes____________
How frequent is this? _________________________________________
Do your legs awaken you at night? No Yes- Why? _________________
Do leg jerks awaken your spouse at night? No Yes _______________________
Do you currently talk in your sleep? No Yes _______________________
Do you currently walk in your sleep? No Yes _______________________
Do you ever awaken feeling totally paralyzed? No Yes _______________________
Have you ever thrown yourself out of bed? No Yes _______________________
Have you ever had a seizure at night? No Yes________________________
As an adult have you ever lost control of your urine during sleep?
No Yes – How often? ___________________________________________
As an adult have you awaken feeling “beat up” or bitten your tongue?
No Yes – How often? ___________________________________________
Do you have hallucinations when you sleep? No Yes______________________________
While awake, do you ever lose muscle strength when you laugh or are stressed?
No Yes ____________________________________________________________
While awake, do you have episodes where you appear to be sleeping but you are not? No Yes ___________________________________________________________
Any other sleep/ wake problems? ________________________________________________
Section 4: Weight History
Are you currently overweight? No Yes
If yes, what did you weigh? 6 months ago ____________ 1 year ago_____________
5 years ago ______________ High School___________
Section 5: Family History
Is there a family history of obesity? No Yes ___________________
Does any one in your family have sleep apnea? No Yes ___________________
Section 6: Past Medical History
Are you being treated for high blood pressure? No Yes – since? ____________
Have you had heart problems? Failure, Heart attack? No Yes ___________________
Do you have lung problems? Asthma, Emphysema? No Yes ________________
Do you have post traumatic stress syndrome? No Yes ________________
Do you have fibromyalgia? No Yes ________________
Are you a diabetic? How long? No Yes ________________
Have you had a stroke? No Yes ________________
Any other neurological problems? ______________________________________________
Do you have a history of acid reflux? (GERD) No Yes ________________
Is it still bothering you? No Yes ________________
Do you have a history of depression/ anxiety? No Yes
Is it currently under control? Yes No _________________
Are you short of breath with activity? No Yes ________________
Any problems breathing thru your nose? No Yes ________________
If yes, explain: _______________________________________________________
Have you had your tonsils removed? No Yes ________________
Have you had Nose/Throat Surgery? No Yes ________________________________
Other head/neck surgery? No Yes ________________________________
Do you have chronic postnasal drainage? No Yes ______________________
Have you been a smoker? How much, how long, when did you quit if you did?
_________________________________________________________________________
Do you drink alcohol? How much, what type and how often? _______________________
_________________________________________________________________________
What other medical/ surgical problems have you had?
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
Section 7: Medication List
Please list your Medicines, including over the counter, vitamins, etc
Section 8: Epworth Sleepiness Scale
How likely are you to “doze off” or fall asleep in the situations described below?
Use the following scale to select the number that fits you and put it in the space.
0 – I would never doze of
1 - There is a slight change I would doze off
2 – There is a moderate chance I would doze off
3 – There is a high chance I would doze off
_____ Sitting and reading
_____ Watching television
_____ Sitting inactive in a public place like a meeting or classroom
_____ As a passenger in a car for one hour
_____ Lying down to rest in the afternoon
_____ Sitting and speaking to someone
_____ Sitting quietly after lunch (without alcohol)
_____ Driving in a car while stopped for a few minutes in traffic
_____ TOTAL
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