McLaren-Greater Lansing Sleep Questionnaire Form
This is McLaren-Greater Lansing Sleep Questionnaire.  This is a secure form.  Please call 517-377-8529 if you have any questions.

use the 'tab' key or mouse to move to the next question.  The 'enter' key will submit your information.


* Indicates required information

Name *




Date of Birth *
 


Age *



Sex  *
 

Height (in inches)  *
 

Weight (in pounds) *



Weight 1 year ago (in pounds)  *


Weight 5 years ago (in pounds)  *


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

What time do you go to bed on WEEKDAYS? *


*

 
WEEKENDS?  *


*


What time do you wake up on WEEKDAYS?  *


 
*

 
WEEKENDS?  *

 
*

 
Do you nap? *


 
How often do you nap? (times per week)

 
How long are the naps? (in minutes)


Do you awaken refreshed? *


Are you a shift worker? *

 
If yes, what kind of shift do you work?


What is your occupation? *


If retired, when?

 
Previous jobs held

 

   
SNORING/BREATHING HISTORY (Please select appropriate answer)
 
Do you snore? *





 
Does your sleep position affect your snoring?  *


 
Have you awakened choking or short of breath?  *




Has anyone noticed that you stop breathing while asleep? *


 
Do you awaken often to urinate during the night?  *




Do you awaken refreshed in the morning?  * 



Do you awaken with an acid or sour taste in your mouth?  *



 
Do you have difficulty sleeping on your back? *



   
SLEEP HISTORY (Plesae check appropriate answer)
 
Do you have difficulty falling asleep?  *


 
Do you have difficulty staying asleep? *


 
Do you wake up too early and cannot get back to sleep? *



 
Do you have thoughts racing through your mind that make it difficult to sleep? *




Have you fallen asleep unexpectantly?  *



Have you ever fallen asleep while driving? *


 
Have you experienced "sleep attacks" (a sudden irresistible urge to sleep)? *




Have you experienced sudden muscle weakness in response to emotions?  *


 
Have you experienced an inability to move while falling asleep or waking up?  *



 
Have you experienced dreamlike images or sounds while falling asleep or waking up? *



 
Do you kick or jerk your arms or legs during sleep?  *




Do you have a creepy, crawly sensation in your legs when lying down?  *


 
Do you have leg cramps (Charley horse)?  *




Do you grind your teeth?  *


 
Do you talk in your sleep? *



Do you have nightmares?  *


 
Have you ever acted out your dreams?  *



Have you ever bitten your tongue while sleeping?  *


   
MEDICAL/SURGICAL HISTORY (please check answer and fill in the blank where appropriate)
 
Have you ever had a sleep study in the past?  *



 
If yes, when?
 

 
If yes, where?


 
Do you use home CPAP or BIPAP?  *


 
If yes, what pressure setting?


 
Do you use home oxygen? *


 
If yes, what liter/flow setting?



Do you have a pacemaker? *




 
Have you ever had a tonsillectomy?  *


 
Have you ever had sinus or nasal surgery?  *




Have you ever broken your nose? *


 
Have you ever had any type of head injury?  *



 
Have you had surgery to promote weight loss?  *



 
If yes, when?
 


Please check the appropriate box if you have a history of any to the following health problem.

















If Other, please specify:

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


 
If yes, Relationship
 

 
Narolepsy?  *



If yes, Relationship


 
Seizure disorder? *


 
If yes, Relationship


 
Depression? *


 
If yes, Relationship



Hypertension? *


 
If yes, Relationship

 
Stroke?  *


 
If yes, Relationship


 
Allergies (please list)


 
List current medication #1 (give medicaiton name, dose (mg) and number of times taken per day)


 
List current medication #2 (give medicaiton name, dose (mg) and number of times taken per day)



 
List current medication #3 (give medicaiton name, dose (mg) and number of times taken per day)


 
List current medication #4 (give medicaiton name, dose (mg) and number of times taken per day)


 
List current medication #5 (give medicaiton name, dose (mg) and number of times taken per day)



 
List current medication #6 (give medicaiton name, dose (mg) and number of times taken per day)


   
SOCIAL HISTORY (please check boxes and fill in the blank where appropriate)
 
Do you smoke?  *


 
If yes, Packs per day?


 
If yes, How long?


 
Have you smoked in the past? *


 
If yes Packs per day?


 
If yes, How long?



 
Do you drink beer wine, liquor? *



If yes, how much 


   
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
 
Sitting and reading *






 
Watching TV  *
 




 
At a public place like a theater or meeting  *






While a passenger in a car for one hour or more  *





 
Lying down in the afternoon *






Sitting and talking with someone  * 





 
Sitting down after lunch  *





 
Stopped at a stoplight  *





 
Total score out of 24: (please add)

 
Do you have any physical limitations we should be aware of?