Sleep Questionnaire UPDATED - Emory Healthcare › ui › pdfs › sleep-center-document… · Do...
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-1- EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today’s Date: _____/_____/______ Name: _____________________________________ Date of Birth: _____/_____/______ Address: ________________________________________________ Sex: Male ☐ Female ☐ City/State/Zip: ________________________________________________________ Preferred Contact Number: ________________________________________________ Work ☐ Home ☐ Cell ☐ Occupation: ________________________________________________ Height: ______ ft ______ in Weight: ______lbs Shirt Collar Size ________inches Name of doctor who referred you: _____________________________________ Doctor’s Phone Number: _____________________________________ Doctor’s Address: _____________________________________ City/State/Zip: ________________________________________________________ Reason for Referral What would you say is your primary sleep problem? (If none, why did your doctor refer you to the sleep clinic?) Describe how and when this problem began, and how often it is occurring. Have you ever had a sleep study? Yes ☐ No ☐ If yes, when and where: ________________________________________________________________________________________ Describe any treatments you have received for your problem: ____________________________________________________________________________________________________________
Transcript of Sleep Questionnaire UPDATED - Emory Healthcare › ui › pdfs › sleep-center-document… · Do...
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EMORYSLEEPCENTERSleepandHealthQuestionnaire
Demographics Today’sDate:_____/_____/______Name:_____________________________________ DateofBirth:_____/_____/______Address:________________________________________________ Sex:Male☐ Female☐City/State/Zip:________________________________________________________PreferredContactNumber:________________________________________________Work☐Home☐Cell☐Occupation:________________________________________________Height:______ft______in Weight:______lbs ShirtCollarSize________inchesNameofdoctorwhoreferredyou:_____________________________________ Doctor’sPhoneNumber:_____________________________________Doctor’sAddress:_____________________________________ City/State/Zip:________________________________________________________ReasonforReferralWhatwouldyousayisyourprimarysleepproblem?(Ifnone,whydidyourdoctorreferyoutothesleepclinic?)
Describehowandwhenthisproblembegan,andhowoftenitisoccurring.
Haveyoueverhadasleepstudy?Yes☐ No☐Ifyes,whenandwhere:________________________________________________________________________________________Describeanytreatmentsyouhavereceivedforyourproblem:____________________________________________________________________________________________________________
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YourSleepHabitsHowmanyhoursofsleepdoyouusuallygetpernight? Whattimedoyouusuallygotobed? Whattimedoyouusuallywakeup? Howlongdoesittakeforyoutofallasleep? Howmanytimesdoyoutypicallywakeupatnight? Whatawakensyou? Ifyouwakeup,onaverage,doyouhavetroublegoingbacktosleep?
Whathoursdoyouwork? Doyoueverrotateshifts?
SymptomsDuringSleep Yes NoDoyoufeelrefreshedafteratypicalnight’ssleep? ☐ ☐Doyoufeelsleepyduringthedayevenwhenyouhavesleptallnight? ☐ ☐Doyounapatleastonceperweek? ☐ ☐Doyoufeelrefreshedafterashortnap? ☐ ☐Doyousleepbetterinareclinerorachairthanyoudoinbed? ☐ ☐Doyoueverexperiencevividdream-likescenesuponawakeningorfallingasleep? ☐ ☐Whenyouareangryorlaugh,doyoueverfeelweakinanypartofyourbody? ☐ ☐Areyoueverunabletomoveorspeakforashortperiodoftimeasyouarefallingasleeporawakening?
☐ ☐
Doyouhaveacreepingorcrawlingsensationinyourlegswhenyouliedowntosleep? ☐ ☐Doyousnore? ☐ ☐Isyourbedpartnerdisturbedbyyoursnoring? ☐ ☐Hasanyoneeverytoldyouthatyourbreathingstopsforbriefperiodsduringthenight? ☐ ☐Doyouhaveabittertasteinthebackofyourthroatwhenyouwakeup? ☐ ☐Doyouwalkortalkinyoursleep? ☐ ☐Doyougrindorclenchyourteethduringyoursleep? ☐ ☐Areyouarestlesssleeper,tossingandturningatnight? ☐ ☐Doyoufeeldrowsywhiledrivingyourcar? ☐ ☐Haveyoueverfallenasleepwhiledriving? ☐ ☐
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Indicate,onaverage,howoftenyouexperiencethefollowingsymptomswhensleepingortryingtosleep.
Symptom TimesPerWeek Daily 4-6 1-3 NeverMymindraceswithmanythoughtswhenItrytofallasleep ☐ ☐ ☐ ☐IoftenworrywhetherornotIwillbeabletofallasleep ☐ ☐ ☐ ☐Fatigue ☐ ☐ ☐ ☐Awakenwithadrymouth ☐ ☐ ☐ ☐Morningheadaches ☐ ☐ ☐ ☐Irritability/Depression ☐ ☐ ☐ ☐Memoryimpairment/Inabilitytoconcentrate ☐ ☐ ☐ ☐Sinustrouble,nasalcongestionorpost-nasaldripinterferingwithsleep
☐ ☐ ☐ ☐
Heartburn,sourbelches,regurgitation,orindigestionwhichdisruptssleep
☐ ☐ ☐ ☐
Painwhichdelays,prevents,orawakensmefromsleep ☐ ☐ ☐ ☐Irresistibleurgestomovemylegsorarmswhileinbed ☐ ☐ ☐ ☐Creepingorcrawlingsensationsinyourlegsbeforefallingasleep
☐ ☐ ☐ ☐
Legsorarmsjerkingduringsleep ☐ ☐ ☐ ☐Frequenturinationdisruptingsleep ☐ ☐ ☐ ☐SleeptalkingorSleepwalking ☐ ☐ ☐ ☐Snoring ☐ ☐ ☐ ☐
EpworthSleepinessScaleThisreferstoyourusualwayoflifeinrecenttimes.Evenifyouhavenotdonesomeofthesethingsrecently,trytoworkouthowtheywouldhaveaffectedyou.Usethefollowingscaletochoosethemostappropriatenumberforeachsituation:0=Wouldneverdoze1=Slightchanceofdozing2=Moderatechanceofdozing3=Highchanceofdozing
Situation ChanceofDozingSittingandreading Watchingtv Sitting,inactiveinapublicplace(eg,atheatreormeetingplace) Asapassengerinacarforanhourwithoutabreak Lyingdowntorestintheafternoonwhencircumstancespermit Sittingandtalkingtosomeone Sittingquietlyafteralunchwithoutalcohol Inacar,whilestoppedforafewminutesintraffic
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MedicalHistoryPleasecheckallpreviouslydiagnosedmedicalconditions:☐ HighBloodPressure ☐ Diabetes ☐ Reflux/Heartburn☐ Highcholesterol ☐ Asthma ☐ Stroke☐ Atrialfibrillation(AFib) ☐ Congestiveheartfailure/Heartfailure☐ DepressionPleaselistanyothersignificantmedicalproblemsandanysurgeriesyouhavehad:
CurrentMedications,prescriptionsandotherwise(withdosesifknown)
FamilyMedicalHistory Age MedicalProblems,(ifdeceased,listcauseofdeath)
Mother Father Brother(s)
Sister(s)
Children
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SocialHistoryDoyoucurrentlysmoke? ☐ Yes ☐ NoPacksperday:______ Howmanyyearshaveyousmoked:______Ifnotcurrentlysmoking,haveyousmokedinthepast? ☐ Yes ☐ No
Whenwasyourlastcigarette?______Numberofalcoholicbeveragesperday:______/perweek:______/permonth:______Howmuchcaffeinatedcoffeedoyoudrinkperday?______cupsHowmuchcaffeinatedtea(hotoriced)doyoudrinkperday?______cups/______glassesHowmuchcaffeinatedsodatoyoudrinkperday?______cansReviewofSystems(pleaseanswerallquestions,checkingyesorno)
Yes No General Comment☐ ☐ Weakness
☐ ☐ Fatigue
☐ ☐ Decreasedappetite
☐ ☐ Increasedappetite
☐ ☐ Weightloss
☐ ☐ Weightgain
☐ ☐ Chills
☐ ☐ Fever
☐ ☐ Nightsweats
Yes No Eyes,Ears,Nose,Throat Comment☐ ☐ Decreasedabilitytosee
☐ ☐ Blurredvision
☐ ☐ Spotsbeforeeyes
☐ ☐ Difficultyhearing
☐ ☐ Ringinginears
☐ ☐ Paininears
☐ ☐ Dischargefromear
☐ ☐ Nosebleeds
☐ ☐ Nasalcongestion
☐ ☐ Post-nasaldrip
☐ ☐ Sinustrouble
☐ ☐ Sorethroat
☐ ☐ Hoarseness
☐ ☐ Paininneck
☐ ☐ Dentaltrouble
☐ ☐ Bleedinggums
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Yes No Respirator Comment☐ ☐ Cough
☐ ☐ Coughupphlegm
☐ ☐ Coughingupblood
☐ ☐ Wheezing
☐ ☐ Asthma
☐ ☐ COPD
☐ ☐ Shortnessofbreath
☐ ☐ Chestpainwithcoughordeepbreathing
Yes No Cardiovascular Comment☐ ☐ Chestdiscomfort
☐ ☐ Shortnessofbreathwhenlyingdown
☐ ☐ Sittinguptobreathe
☐ ☐ Heartracing
☐ ☐ Swellingoflegs
☐ ☐ Varicoseveins
☐ ☐ Legpainwithexertion
☐ ☐ Blue/purplecolorofhands/feet
Yes No Gastrointestinal Comment☐ ☐ Nausea
☐ ☐ Vomiting
☐ ☐ Diarrhea
☐ ☐ Constipation
☐ ☐ Heartburn
☐ ☐ Abdominalpain
☐ ☐ Brightredbloodinstools
☐ ☐ Blackstools
☐ ☐ Changeinbowelhabits
☐ ☐ Hemorrhoids
Yes No Musculoskeletal Comment☐ ☐ Painfuljoints
☐ ☐ Swellingofjoints
☐ ☐ Rednessofjoints
☐ ☐ Stiffnessofjoints
☐ ☐ Deformitiesofjointsorextremities
☐ ☐ Musclepain
☐ ☐ Backpain
☐ ☐ Painrunningdownthebackofyourlegs
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Yes No Endocrine Comment☐ ☐ Goiter
☐ ☐ Heatintolerance
☐ ☐ Coldintolerance
☐ ☐ Tremuloushands
☐ ☐ Changeinpitchofvoice
☐ ☐ Increasedbodyhair(face,underarmsorpubic)
☐ ☐ Decreasedbodyhair
☐ ☐ Lossofperiods
☐ ☐ Increasedthirst
☐ ☐ Increasedurination
Yes No Neurologic/Psychiatric Comment☐ ☐ Nervousness/Anxiety
☐ ☐ Depression
☐ ☐ Difficultywithmemoryforpastevents
☐ ☐ Difficultywithmemoryforrecentevents
☐ ☐ Difficultywiththinkingorproblemsolving
☐ ☐ Headaches
☐ ☐ Blackouts
☐ ☐ Dizziness
☐ ☐ Doublevision
☐ ☐ Paralysisorweaknessinlimb(s)
☐ ☐ Lossofsensation
☐ ☐ Lossofbalance
☐ ☐ Lossofcoordination
☐ ☐ Difficultyinspeaking
☐ ☐ Seizuresorspells
Yes No Hematologic/Allergy Comment☐ ☐ Anemia
☐ ☐ Blooddisorder
☐ ☐ Immunocompromised
☐ ☐ Seasonalallergies
☐ ☐ Drugallergies
Yes No Skin Comment☐ ☐ Itching
☐ ☐ Rashorulcers
☐ ☐ Changeincolor
☐ ☐ Changeintextureofhairorhairloss
☐ ☐ Nailchanges
