Patient Questionnaire

Sleep Disorders Center


PeaceHealth St. John Medical Center, Longview

 

NAME ___________________________________ AGE_____ DATE OF BIRTH ____________
                     (include middle initial)                                                                   
DATE OF APPOINTMENT ______________


________________________________________________________________________________________________________________________________

Briefly describe your main sleep problem:

 

 

 

 

 

Do you have any other complaints about sleep? If yes, please describe.

 

 

 

 

If you currently take any medications for sleep, please list the name and what time you take it. ____________________________________   ____________________________________

____________________________________   ____________________________________

____________________________________   ____________________________________

____________________________________   ____________________________________

 

If you have taken any over the counter or prescription medications for sleep in the past, please list them:

____________________________________   ____________________________________

____________________________________   ____________________________________

____________________________________   ____________________________________

____________________________________   ____________________________________

 

For questions below, please circle answers and fill in blanks.

 

Do you have a regular bed partner?                                                 yes                  no

How do you feel as bedtime approaches? (please circle)

            Looking forward to sleep                     Calm   Anxiety                        Angry              Worried          

 

Do you smoke a cigarette just before going to sleep?           yes                  no                    occasionally   

Do you have caffeine within four hours of bedtime?              yes                  no                    occasionally

Do you drink alcohol within two hours of bedtime?                yes                  no                    occasionally   

Do you exercise within four hours of bedtime?                                  yes                  no                    occasionally

 

What time do you usually get into bed?  Weekdays ____________ Weekends ____________

Do you try to fall asleep right away?  yes                  no

            If no, what do you usually do in bed before sleep?  please circle all that apply:

                  Read               Watch television                      Listen to music                        Use computer       Talk on phone

                  Other______________________________________________________________________

Is your bedroom dark and quiet?       yes                  no       

            If no, please describe______________________________________________________________

For questions below, please circle answers and fill in blanks.

 

How long does it take you to fall asleep?_____ minutes _____ hours

How many times do you wake up during the night?_______________

            What do you do during awakenings? Please circle all that apply.

                        Change position                      Look at the clock                    Read   Get out of bed             Go to the bathroom                                       Watch television                      Eat                   Drink water                  Smoke a cigarette                                                                                                       Other_______________________________________________________________________

 

After an awakening how long does it take you to get back to sleep?______________________________

What time do you usually get up in the morning?  Weekdays __________  Weekends __________

Do you use an alarm:             yes                  no                    If yes, for what time is it set?__________________________

How many hours of sleep do you get each night? Weekdays____________           Weekends____________

How do you sleep away from home?             Same              Better              Worse

 

Do you:

Feel refreshed when you get up in the morning?              yes                  no       

Feel sleepy during the day?                                                                                   yes                  no       

        If yes, how long ago did this start? ______________________________

Doze or fall asleep when you do not intend to?                yes                  no       

        If yes, what are you doing when you doze? (circle all that apply)

                        Inactive              Reading       Watching Television    Working at the computer        During meetings

                        At the movies/theater     Talking to someone    Other____________________________________

Feel drowsy while driving?                                                                                     yes                  no       

        If yes, have you ever fallen asleep while driving?                  yes                  no       

Take deliberate naps?                                                                                            yes                  no       

        If yes, what is the usual time of your naps and how long do you sleep?

                    Time ____________________________ Length _________________________________

            How many naps do you take weekly? _____________

 

Do you snore?  yes     no        occasionally                do not know

            Does your snoring disturb others?                 yes                  no                    do not know

            Do you wake yourself with your snore?         yes                  no       

Have you awakened with a gasp, feeling short of breath or choking?                      yes                  no       

Has anyone observed pauses in your breathing while you were sleeping?  yes                  no       

Do you have dry mouth in the morning?                    yes                  no       

Do you awaken with a headache?                             yes                  no       

Do have a preferred sleep position?               yes                  no                    Back    Stomach         Side

 

                                                                                                                                               

 

 

For questions below, please circle answers and fill in blanks.

 

Have you ever:

            Had sudden bouts of muscle weakness caused by laughter or strong emotion?     yes                  no           

            Felt unable to move while falling asleep or waking up?        yes                  no       

            Felt you were dreaming while awake?                                                           yes                  no       

            Had any of the following behaviors during sleep?  Please circle all that apply.

                        Talking            Walking                       Yelling out       Appear to act out your dreams

                                    If yes, what part of the night do they occur?

                                                First half                      Second half                 Anytime                       Varies

 

Do you have uncomfortable feelings in your legs while inactive?                 yes                  no       

            If yes, please circle the words that best describe these feelings:

                        Creeping         Crawling                      Itching Tingling              Aching          Tension                       Difficult to describe

                        Other__________________________________________________________________________

                                    Do the feelings cause you an urge to move your legs?         yes                  no

                                    Does movement decrease or stop these feelings?                yes                  no       

                                    What time of the day do the feelings usually start? __________________________________

                                    Do the feelings occur only when you are inactive?               yes                  no       

                                    Are the feelings worse in the evening?                                                          yes                  no                   

                                    Are the feelings worse in bed?                                                                                   yes                        no       

                                    Do the feelings interfere with your sleep?                                          yes                  no           

Has anyone ever told you that your legs move while you are asleep?          yes                 no       

 

Have you had any of the following medical problems? (please circle answer for each)

            High blood pressure    yes / no

            Heart attack    yes / no

            Atrial fibrillation      yes / no

            Heart valve disease    yes / no                              

            Alzheimer’s disease    yes / no                                

            High cholesterol  yes /  no

            Asthma  yes /  no

            Emphysema      yes /  no

            Deviated septum     yes / no

            Bronchitis     yes  /  no

            Reflux  yes  /  no

            Fibromyalgia   yes /  no

            Arthritis  yes / no

            Heartburn   yes / no

            Stroke   yes / no

Seizures                                              yes                  no

Neuropathy                             yes                  no

Dementia                                yes                  no

Anemia                                                yes                  no

Iron deficiency            yes                  no

Kidney disease                        yes                  no

Cancer                                    yes                  no Type:______________

Diabetes                                  yes                  no

Thyroid disease                       yes                  no

Depression                              yes                  no

Bipolar disorder                       yes                  no

Anxiety                                                yes                  no

Other__________________________________________

Other__________________________________________

 

 

Have you had a tonsillectomy?                      yes                  no

 

 

 

 

 

 

 

Please list any other surgeries or hospitalizations and when:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

                                                                                                                                                                                           

 

For questions below, please circle answers and fill in blanks.

 

Do you have any medication allergies or serious side effects?        yes                  no

            If yes, please list the medication and the reaction it causes (if current Peace Health patient, only list                         changes since last visit with your physician):

            __________________________________________________________________________________

            __________________________________________________________________________________

            __________________________________________________________________________________

            __________________________________________________________________________________

 

Do you have any other allergies? (food, pollen, dust, animals, etc.)             yes                  no

            If yes, please list and the reaction it causes (if current Peace Health patient, only list changes since last      visit with your physician):

            __________________________________________________________________________________

            __________________________________________________________________________________

            __________________________________________________________________________________

            __________________________________________________________________________________

 

Please list all medications you take, including over the counter medications (if current Peace Health patient, only list changes since last visit with your physician):

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

__________________________________________                        ________________________________________

 

 

 

 

 

 

 

 

 

Personal/Social history:

 

Occupation: ____________________________________________

Education:  _____________________________________________

Other household members:   

            none    husband                      wife                 partner             mother             father   children                       roommate

Number of children:    sons_____________              daughters_____________

 

Caffeine:         How much of these caffeinated beverages do you drink?

            Coffee_____________           Tea____________      Soda__________        Energy Drink___________

Alcohol:                       How much of these alcoholic beverages do you drink?

            Beer_____________________          Wine____________________                        Liquor____________________

Cigarettes:       never   quit      (when: ________________) current smoker

            How many packs per day? ________________________                How many years: ______________

 

 

 

For questions below, please circle answers and fill in blanks.

 

Family history:

Any family members with the following sleep disorders?  Yes          No                  If yes, list family members:

            Obstructive sleep apnea         __________________            Restless legs syndrome            __________________

            Snoring                        ____________________________                Narcolepsy            _____________________________

            Insomnia         ____________________________                Behaviors during sleep _____________________

Other pertinent family history:

            Mother:            alive / deceased          age______      medical problems____________________________________

            __________________________________________________________________________________

 

            Father:  alive / deceased        age______      medical problems____________________________________

            __________________________________________________________________________________

 

            Sibling’s medical problems: ____________________________________________________________

            __________________________________________________________________________________

            Children’s medical problems:___________________________________________________________

            __________________________________________________________________________________

 

Current weight: ______ pounds; weight 5 years ago: ______ pounds; weight ten years ago: _____ pounds

 

PeaceHealth Medical Group Sleep Disorders Center
1615 Delaware St
P.O. Box 3002
Longview, WA 98632
360-414-7800
Fax: 360-414-7808
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