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Sleep Health History

Today's Date: June 21, 2024

First Participant's Name

First Name*

Last Name*
First Participant's 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*
Second Participant's 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*
Third Participant's 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*
Fourth Participant's 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*
Fifth Participant's 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*
Sixth Participant's 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*
Seventh Participant's 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*
Eighth Participant's 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*
Ninth Participant's 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*
Tenth Participant's 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*
Parent or Guardian's 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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