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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