Patient Questionnaire Form

Patient Information

Sleep Complaints



Medical problems

Current Medications

Sleep pattern


Sleep habits

Social History

Prior sleep evaluation and treatment

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




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