Patient Sleep History

Patient Sleep History
Date:

MonthDayYear
Date
First Name:
Middle Name:
Last Name:
Date of Birth:

MonthDayYear
Date
Weight:
Height:
Occupation:
This Sleep History helps your Sleep Specialist gain a more in-depth understanding of your Sleep/Medical background and the nature of your current sleep problem(s). Please complete all the questions as thoroughly as you can.
1.Describe your main sleep problem(s) and/or sleep complaint(s):
How often do these symptoms occur?

Other
How long have you been experiencing these symptoms?
I am currently on:

Other
Do you have difficulty with?
How long does it take you to fall asleep?
How many times do you typically wake up at night?
Are your sleep habits on weekends different from the rest of the week?
Describe your weekend sleep habits
Do you usually:
Do you work split shifts or rotating shifts?
Do you work Nights?
Do you work Evenings?
Do you feel refreshed after a short nap?
How do you feel after an average night of sleep?
For how long do you feel this way?
When do you feel at your best?
What time do you usually go to bed?
What time do you usually get out of bed?
14. In response to intense emotion (laughter, anger, surprise) have you felt muscle weakness in your legs, neck, arms, eyes, etc?
If yes above, please describe emotions involved and what muscles were weakened or went limp.
Before you are fully asleep do you have very vivid, sometimes frightening, hallucination like dreams?
Have you ever awakened and felt like your body was "paralyzed", or couldn’t move at all, even though you could breathe and see?
Describe Your Usual Daily Routine
PLEASE CHECK ALL THAT APPLY TO YOUR USUAL ROUTINE:

Other
Weight Changes

Within the last three years enter total weight gained or lost
Weight Gained:
Weight Lost:
Substance Intake
Do you or someone in your household smoke? Cigarettes/cigars/pipe, etc
Do you use tobacco?
If yes, what type(s) and how often?
(tabacco use)
Do you use alcohol?
If yes, how much and how often?
(alcohol use)
Do you use caffeine or other stimulants?
If yes, how much and how often?
(caffeine or stimulant use)
ALLERGIES: Are you allergic to Latex, tape or adhesive?
Do you have any other allergies, drug or otherwise? (Please list all known allergies in the space provided)
PAIN: Describe any pain you experience and how often:
FALLS: Have you fell in the last 5 years?
Have you sustained any injuries from falls ?
Sleeping Position Preferences

Choose which option you prefer, or find yourself sleeping most often
Choose one of the following six options
Choose as many as apply to you.
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. If you haven’t done some of these activities recently, please try to estimate how you would typically respond. A score of 11 or more is often sufficient for insurance companies to approve warranted services.

Use the following scale to choose the most appropriate number for each situation:

0 = would never sleep

1 = slight chance of sleeping

2 = moderate chance of sleeping

3 = high chance of sleeping
Watching TV
Sitting and Reading
Sitting and talking with someone
Sitting quietly after a lunch without alcohol
As a passenger in a car for an hour without a break
In a car, while stopped for a few minutes in the traffic
Sitting inactive in a public place (ex. a theater or meeting)
Lying down to rest in the afternoon when circumstances permit
EPWORTH SCORE
EPWORTH SCORE - Result
Current Prescription and non-prescription Medications.

Rows	NAME OF MEDICATION	AMOUNT	HOW OFTEN	DIAGNOSIS/REASON FOR MEDICATION

Please check all that apply:

Other
Surgeries:
List any past surgeries
Other medical history not listed above:
List other medical history
Bed Partner Questionnaire

To be completed by bed partner or guardian
Name of person completing this form
Relationship to patient
Check all that apply:
Please describe any other sleep behaviors. Please Include: (1) description of behavior, (2) time it occurs, (3) how often, (4) whether it occurs every night.
Should be Empty:

Patient Sleep History

Describe Your Usual Daily Routine

Weight Changes

Substance Intake

Sleeping Position Preferences

Epworth Sleepiness Scale

Current Prescription and non-prescription Medications.

Bed Partner Questionnaire