1. What time do you typically go to bed?

2. Do you have difficulty falling asleep at the beginning of the night? |  Yes or No
    If yes, on average how long does it take to fall asleep?

3. Do you plan your next day's activities while lying in bed trying to fall asleep? |  Yes or No

4. Do you have racing thoughts going through your mind while trying to fall asleep
or after waking up in the middle of the night? | Yes or No

5. Do you have difficulty staying asleep throughout the night? | Yes or No
    If yes, how many times do you wake up during the night?

6. How long does it take you to fall back to sleep?

7. Do you take medications to fall or stay asleep? | Yes or No
    If yes, please state medication name and dosage:     
     

8. When do you typically wake up to start your day?
    Do you need an alarm clock? | Yes or No

9. Do you feel refreshed when you awaken to start your day? | Yes or No

10. Do you experience an unsettled, restless sensation in your legs while lying in bed? | Yes or No
      If yes, how often? | Rarely (25%)   | Half the time (50%) |  Most of the time (75% or more) |
      If yes, does movement of your legs calm down the restless sensations at least briefly? | Yes or No

11. Have you been told that you make kicking and twitching movements while asleep? | Yes or No

12. Do you snore at night? | Yes or No
      If yes, how would you rate the severity? | Mild   | Moderate   | Severe |

13. Have others told you that you have pauses in breathing or that you make
      frequent gasping sounds when sleeping? Yes or No
      If yes, how frequent are the pauses or gasping? Throughout the night Frequently Occasionally

14. Does your bed partner frequently sleep in another room because of how you sleep? Yes or No

15. Check those that apply to you: Do you frequently wake up with a:
     dry mouth  
     headaches
     excessive sweating
     heart burn  
     aching jaws (or grind or clench your teeth in your sleep)
     choking or gasping
     nasal congestion on awakening (which was not present when you went to bed)
     chest pain  
     drooling on the pillow

16. Do you have difficulty maintaining concentration? | Yes or No
     Are you sleepy during the day? | Yes or No

17. Do you take naps often? | Yes or No  
      if so for how long?
      Do you usually dream during these naps? | Yes or No

18. How many caffeinated beverages do you consume each day?
     How many alcoholic beverages do you consume each day?    
     How many tobacco products do you consume each day?          Type:

19. Do you occasionally awaken feeling paralyzed? | Yes or No

20. Do you experience sudden loss of strength in your legs or arms during the day? | Yes or No
     If yes, are these brought on by a sudden frightening event or laughter? | Yes or No

Rank how likely it would be for you to become drowsy ( in contrast to feeling just tired ) in the following situations:

0=never become drowsy

1=rarely become drowsy

2=frequently become drowsy

3=always become drowsy

Sitting and reading: 0 1 2 3

Watching TV: 0 1 2 3

Sitting, inactive in a public place (e.g. theater): 0 1 2 3

As a passenger in a car for an hour without a break: 0 1 2 3

Lying down to rest in the afternoon when circumstances permit: 0 1 2 3

Sitting and talking to someone: 0 1 2 3

Sitting quietly after lunch without alcohol: 0 1 2 3

In a car, while stopped for a few minutes in the traffic: 0 1 2 3

My sleep problems are:

My other medical problems are:

My medications are:

Have you had a sleep study before? |  Yes or No     

Have you had surgery for sleep apnea before? |  Yes or No   

Are you currently on CPAP/BiPAP? |   Yes or No  
Are your responses to 1-21 above WITH or WITHOUT using CPAP/BiP ? |   With or Without  

Do you need assistance at night by other people? |  Yes or No       

Do you have COPD? |  Yes  or No   

Are you on Oxygen at night? | Yes or No  

Who filled out this Questionnaire?

Referring Physician:
Physician Phone Number:
Insurance:

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 Thank you for participating !