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Sleep Health History

Today's Date: June 6, 2025

First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Hypertension*
No
Yes
High Blood Pressure*
No
Yes
History of Stroke*
No
Yes
Type 2 Diabetes*
No
Yes
Heart Disease*
No
Yes
Mood Disorders*
No
Yes
Insomnia*
No
Yes
Impaired Cognition*
No
Yes
Associated Comorbidities

Epworth Sleepiness Scale

Scoring:

  • 0 = No chance of dozing or sleeping
  • 1 = Slight chance of dozing or sleeping
  • 2 = Moderate chance of dozing or sleeping
  • 3 = High chance of dozing or sleeping

Sitting and reading *
Watching TV *
Sitting inactive in a public place *
As a passenger in a car for an hour without a break *
Lying down to rest in the afternoon *
Sitting and talking to someone *
Sitting quietly after a lunch without alcohol *
In a car, while stopped for a few minutes in traffic *
Total *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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