Sleep Disorders Center of Connecticut | Branford, Hamden, Milford, Norwalk

Patient Questionnaire Form 01/01

Patient Information

First Name*

Last Name*

Email*

Date of Birth*

Referring Physician Name

Today Date

Sleep Complaints

Insomnia

Difficulty with sleep onset

Frequent prolonged awakenings

Early morning awakenings

Restlessness

Irresistible urge to move legs at rest

Involuntary limb movements

Unpleasant sensation in legs

Grinding teeth in sleep

Unwanted Events/Behavior

Night Terrors

Nightmares

Sleepwalking

Talking

Other

Do you get elbow from the bed partner each night?

Medical problems

Current Medications

Use of sleeping pills

Sleep pattern

	Weekdays	Days off
Typical bedtime
Number of awakenings per night
Number of hours of sleep per night
Typical wake up time
Number and timing of naps

Family history of sleep problems

Sleep habits

I usually watch TV or read in the bed prior to sleep

I check my alarm clock many times during the night

I drink alcohol prior to bedtime

I smoke prior to bedtime or upon awakening during the night

I eat a snack at bedtime

My dinner is at

Height(ft)

Height(In)

Weight(lbs)

Age

Social History

Marital status

Single

Married

Divorced

Widowed

Employment status

Employed

Unemployed

Retired

Occupation

Job hours

My job requires driving a vehicle

I work with dangerous equipment

I am a student

Smoking

Yes

Smoking Amount

Alcohol

Yes

Alcohol Amount

Prior sleep evaluation and treatment

Any prior sleep studies

Yes

Date

Result

Are you currently on CPAP?

Yes

How long

Pressure

History of ENT surgery for OSA?

Yes

Date

Result

Any additional information you want to provide for the physician interpreting your sleep study

Epworth sleepiness scale

How likely are you going to doze off or fall asleep in the following situations? Rate each description according to your normal way of life in recent time. Use the following scale (0=would never doze; 1=slight chance of dozing; 2== moderate chance; 3== high chance of dozing)

Chance of dozing

Sitting and reading

Watching TV

Sitting inactive in a public place (e.g.. a theater or meeting)

Sitting as a passenger in a car, for an hour without a break

Lying down to rest in the afternoon when your schedule permits it

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

Sitting in a car, while stopped for a few minutes in the traffic

Total score