Sleep Study Questionnaire Form for McLaren Clarkston

This is McLaren Oakland and McLaren Clarkston Sleep Questionnaire Form.  This is a secure form.  Please call 248) 922-6840 if you have any questions. Use the 'tab' key or mouse to move to the next question.  The 'enter' key will submit your information.
Name*:
Email*:
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:
Do you have any physical limitations we should be aware of?