Form

Date

First Name

Last Name

Date Of Birth

Height

Weight

Allergies

Primary Care Physician

Sleep Habits

What is your normal bedtime?

What time do you normally wake up?

How long does it take you to fall asleep?

How many times do you usually wake up?

How many of those times is it to use the bathroom?

How many naps do you take in a typical week?

What is your average nap length?

Sleep Problems

In your own words, what is your sleep related problem?

Do you usually sleep with someone else in your bed?

Do they complain about you snoring?

Do they ever report that you stop breathing in your sleep?

Does your snoring ever awaken you?

Do you ever feel unpleasant sensations in your legs? (Crawling feeling, need to move a lot)

Do you wake up tired or feel tired during the day?

Do sleep problems ever interfere with your work or other responsibilities?

When sleeping how often do you: (select one)

Please list all current medications:

Health History (circle all that apply)

Family History (circle all that apply)

Smoking:

How much per day?

Quit Smoking: When?

Exercise: How many times per week?

Alcohol consumption: How much per day?

Caffeinated drinks: How many per day?

Sleeping pill use: What type and dosage?

What is your occupation?

What are your normal work or school hours?

Epworth Sleepiness Scale

Instructions: Be as truthful as posible. Rate your sleepiness on a scale of 0-3 and fill in your responses for the situations. Total all of your entries and enter the total in the final box.

0 = Would never doze.

1 = Slight chance of dozing.

2 = Moderate chance of dozing

3 = High chance of dozing

Sitting and reading:

Watching Television

Sitting inactive in a public place like a theater or meeting.

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 lunch when you've had no alcohol.

In a car while stopped in traffic.

Total Score

STOP BANG Questionnaire

Height (inches/cm)

Weight (lb/kg)

Age

BMI

Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Do you often feel tired, fatigued, or sleepy during daytime

Has anyone observed you stop breathing during your sleep?

Do you have or are you being treated for high blood pressure?

BMI more than 35 kg/m2?

Age over 50 years old?

Neck circumfrence greater than 40cm?

Gender male?