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
P.O. Box 3002