Sleep Questionnaire for McLaren Greater Lansing

Name*: Date of Birth*:   Age*: Gender*:   Male Female 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? * AM or PM? * AM PM   Weekends? * AM or PM? * AM PM What time do you wake up on Weekdays? *   AM or PM? * AM PM   Weekends? *   AM or PM? * AM PM   Do you nap? * YES NO   How often do you nap (times per week)?   How long are the naps (in minutes)? Do you awaken refreshed? * YES NO Are you a shift worker? * YES NO   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? * Do Not Know Sometimes Yes No   Does your sleep position affect your snoring? * YES NO   Have you awakened choking or short of breath? * YES NO Has anyone noticed that you stop breathing while asleep? * YES NO   Do you awaken often to urinate during the night? * YES NO Do you awaken refreshed in the morning? * YES NO Do you awaken with an acid or sour taste in your mouth? * YES NO   Do you have difficulty sleeping on your back? * YES NO SLEEP HISTORY (Plesae check appropriate answer)   Do you have difficulty falling asleep? * YES NO   Do you have difficulty staying asleep? * YES NO   Do you wake up too early and cannot get back to sleep? * YES NO   Do you have thoughts racing through your mind that make it difficult to sleep? * YES NO Have you fallen asleep unexpectedly? * YES NO Have you ever fallen asleep while driving? * YES NO   Have you experienced sleep attacks (a sudden irresistible urge to sleep)? * YES NO Have you experienced sudden muscle weakness in response to emotions? * YES NO   Have you experienced an inability to move while falling asleep or waking up? * YES NO   Have you experienced dream-like images or sounds while falling asleep or waking up? * YES NO   Do you kick or jerk your arms or legs during sleep? * YES NO Do you have a creepy, crawly sensation in your legs when lying down? * YES NO   Do you have leg cramps (Charley horse)? * YES NO Do you grind your teeth? * YES NO   Do you talk in your sleep? * YES NO Do you have nightmares? * YES NO   Have you ever acted out your dreams? * YES NO Have you ever bitten your tongue while sleeping? * YES NO MEDICAL/SURGICAL HISTORY (please check answer and fill in the blank where appropriate)   Have you ever had a sleep study in the past? * Yes No   If yes, when?     If yes, where?   Do you use home CPAP or BIPAP? * Yes No   If yes, what pressure setting?   Do you use home oxygen? * Yes No   If yes, what liter-flow setting? * Do you have a pacemaker? * Pacemaker Pacemaker/defibrillator No   Have you ever had a tonsillectomy? * Yes No   Have you ever had sinus or nasal surgery? * Yes No Have you ever broken your nose? * Yes No   Have you ever had any type of head injury? * Yes No   Have you had surgery to promote weight loss? * Yes No   If yes, when?   Please check the appropriate box if you have a history of any of the following health problems: * Hypertension Heart Attack Congestive Heart Failure Cardiac Arrhythmias Diabetes Lung problems/COPD/Asthma Stroke/TIA Reflux Arthritis Fibromyalgia Sexual dysfunciton/loss of libido Depression, Anxiety Seizures None Other If Other, please specify: Family History Does any member of your family have the following?   Sleep Apnea? * Yes No   If yes, Relationship:   Narcolepsy? * Yes No If yes, Relationship:   Seizure disorder? * Yes No   If yes, Relationship:   Depression? * Yes No   If yes, Relationship: Hypertension? * Yes No   If yes, Relationship:   Stroke? * Yes No   If yes, Relationship:   Allergies (please list):   List current medication 1 - give medication name, dose (mg) and number of times taken per day:   List current medication 2 - give medication name, dose (mg) and number of times taken per day:   List current medication 3 - give medication name, dose (mg) and number of times taken per day:   List current medication 4 - give medication name, dose (mg) and number of times taken per day:   List current medication 5 - give medication name, dose (mg) and number of times taken per day:   List current medication 6 - give medication 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? * Yes No   If yes, Packs per day?   If yes, How long?   Have you smoked in the past? * Yes No   If yes Packs per day?   If yes, how long?   Do you drink beer - wine - liquor? * Yes No 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: * 0 = never 1 = occasionally 2 = often 3 = usually   Watching TV: *   0 = never 1 = occasionally 2 = often 3 = usually   At a public place like a theater or meeting: * 0 = never 1 = occasionally 2 = often 3 = usually While a passenger in a car for one hour or more: * 0 = never 1 = occasionally 2 = often 3 = usually   Lying down in the afternoon: * 0 = never 1 = occasionally 2 = often 3 = usually Sitting and talking with someone: * 0 = never 1 = occasionally 2 = often 3 = usually   Sitting down after lunch: * 0 = never 1 = occasionally 2 = often 3 = usually   Stopped at a stoplight: * 0 = never 1 = occasionally 2 = often 3 = usually   Total score out of 24 (please add):   Do you have any physical limitations we should be aware of?