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Sleep Study Questionnaire

Sleep Study Questionnaire Form






 





 

 







SLEEP SCHEDULE (Please provide the following information, circle answer where appropriate)




 






 

 

 

 


 


 






 





 


SNORING/BREATHING HISTORY (Please select appropriate answer)
 




 


 





 








 



SLEEP HISTORY (Plesae check appropriate answer)
 


 


 


 








 





 


 


 





 





 





 






MEDICAL/SURGICAL HISTORY (please check answer and fill in the blank where appropriate)
 


 

 

 



 


 



 


 







 


 





 


 


 

 























Family History Does any member of your family have the following?
 


 



 





 


 



 


 






 



 


 



 



 



 



 



 



 



 




SOCIAL HISTORY (please check boxes and fill in the blank where appropriate)
 


 



 



 


 



 



 






WORTH SLEEPINESS SCALE-How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired. Please check the most appropriate answer using the following scale and total your points