Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. |
My Main Sleep Complaint(s) Is: |
Trouble falling asleep at night |
Waking up in the middle of the night |
Waking up early |
Being sleepy all day |
Snoring |
Waking up choking or gasping for air or have been told to be choking at night |
Unwanted behaviors during sleep |
Other |
If unwanted behaviors during sleep or other, please explain:
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Typical bedtime *
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Typical wake up time: *
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Typical number of awakenings per night: *
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Typical time you usually wake up at night? *
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Total amount of sleep per night: *
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Number and duration of naps per day: *
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List any activities that you normally do during nighttime awakening(s), i.e. restroom, eat, watch TV:
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Please check all of the following statements that are true about your sleep: Habits and Symptoms During Wake Times at Night |
I have physical tension or restlessness |
I grind my teeth |
I have restless legs |
I feel bloated and/or hungry |
I have itchiness |
My mind is calm and quiet and I am able to think about projects, watch TV, or read |
My mind is irritated, confused and tired, I am unable to read or concentrate |
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I have dreams of control / direction / movement / navigation |
I have dreams of loss of home / property / territory / valuables |
I have dreams of vulnerability, exposure, and shame |
I have dreams of threat, danger, feelings of fear, nightmares |
I have night terrors, dreams of guilt, unfinished business, non-acceptance |
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I have a tendency to fall asleep during the day |
I have had "blackouts" or periods when I am unable to remember what just happened |
I have fallen asleep while driving |
I fall asleep while watching TV |
I fall asleep during conversations |
I fall asleep in sedentary situations |
I have had injuries as the result of sleepiness |
I performed poorly in school because of sleepiness |
I have had an inability to move while falling asleep or when waking up |
I have had hallucinations or dreamlike images or sounds when falling asleep or waking up |
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Cups/bottles/cans per day:
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Time of the last caffeinated drink:
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What kind of alcoholic drinks and how much? Have you noticed if it affects your sleep?
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What do you smoke and how often?
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Sleep alone |
Share a bed with someone |
My job requires driving a vehicle |
I work with dangerous equipment or substances |
I am a shift worker on rotating shifts |
I am a permanent or long-term, third-shift worker |
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Specify sources(s)
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Specify sources(s)
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Specify sources(s)
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Temperate of room you sleep in (Farenheit): *
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Past Sleep Evaluation and Treatment |
I have had a previous sleep disorder evaluation |
I have had a previous overnight sleep study |
I have been prescribed, mandibular advancement device, CPAP or bilevel PAP machine for home use |
I have had surgical treatment for a sleep disorder |
I have previously been prescribed medication for a sleep disorder |
I have previously been treated for a sleep disorder |
If you have been prescribed medication, please describe type of medication, also what helped, what did not help.
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