Background Questionnaire

BACKGROUND QUESTIONNAIRE

Complete this form only if our office requests it from you.
Date*

MonthDayYear
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Who filled in this form?*

PatientOther
Please state briefly why you are requesting an appointment.*
On WEEKDAYS, when do you usually go to bed?*

:HourMinutesAM/PM Option
And wake up?*

:HourMinutesAM/PM Option
On WEEKENDS, when do you usually go to bed?*

:HourMinutesAM/PM Option
And wake up?*

:HourMinutesAM/PM Option
How long does it take you to fall asleep at night? (Guess is OK) *
MINUTES
Do you have any frequent awakenings during sleep?*

YesNo
How often?
Are awakenings related to needing to use restroom?*

YesNo
Have you ever had a sleep study before?*

YesNo
Do you snore?*

YesNoI don't know

If yes, please rate the loudness of snoring

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is Loudest

Have you been informed that you stop breathing or “gasp” while asleep?

YesNoI don't know
Do you wake up with a headache in the morning at least once a week?*

YesNoI don't know
Have you had uncomfortable sensations in your legs worsened with prolonged rest or during the evening hours and relieved by movement?*

YesNoI don't know
Do you kick your legs while asleep?*

YesNoI don't know
Have you experienced sudden muscle weakness (e.g. legs, neck) after laughing or strong emotion?*

YesNoI don't know
Have you awoken from sleep able to look around but unable to move or speak for a short time?*

YesNoI don't know
Have you ever seen images, heard sounds, or felt something that was not present when drowsy or upon awakening from sleep?*

YesNoI don't know
Please indicate if any of the following behaviors occur during your sleep (please check all that apply):*

SleepwalkingBedwettingDry mouthAwakening with heart palpitationsSleep talking / shouting / swearingBody jerkingHeartburnFrequent nightmaresNocturnal coughExcessive sweatingTeeth grindingNone applyOther
How many servings of caffeine do you consume on a typical day?*
How many alcoholic beverages do you consume in an average week?*
Do you use recreational drugs?*

YesNo
If yes, which ones and how often?
Do you use tobacco?*

YesNo
If yes, how much?
What is your height?
Ex. 5 feet 8 inches
How much do you weigh?
lbs.
Neck circumference
Ex. 15 inches
Surgical / Medical History*

TonsillectomyDeviated nasal septum surgeryOrthodontia/BrackesSinus surgerySurgery for sleep apnea / UPPPCoronary artery bypassCardiac angioplasty / stentsPacemaker / AICD implantationNeck surgeryBack surgeryStroke/TIAAlzheimer's / Other dementiaSeizure DisorderParkinson's diseaseHigh blood pressureAtrial fib / Cardiac arrhythmiasCongestive heart failureGERD / HeartburnDiabetes mellitusHypothyroidismHigh cholesterolAllergic rhinitisCOPDAsthmaAnemiaFibromyalgiaMigraine headacheNoneOther
Psychiatric History*

Suicidal thoughtsThoughts of harming othersInpatient hospitalizationSchizophreniaBipolar disorderDepressive disorderAnxiety disorderAlcohol / Drug dependenceAttention deficit-hyperactivity disorderEating disorderNoneOther

Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, incontrast to just feeling tired? This refers to your usual way of life in recenttimes. Even if you have not done some of these things recently try to workout how they would have affected you. Use the following scale to choose themost appropriate number for each situation.

0 = would never dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation*

Rows	Chance of Dozing
Sitting and Reading
Watching TV
Sitting, in active in a public place (e.g. theater, or meeting)
As a passenger in a car without a break
Lying down to rest in the afternoon when circumstances permit
Sitting, talking with someone
Sitting quietly after a lunch without alcohol
In a car, while stopped a few minutes in traffic

Rows	Very satisfied	Satisfied	Moderately	Dissatisfied	Very Dissatisfied
How SATISFIED/DISSATISFIED are you with your CURRENT sleep patern?

Click submit below to send your forms to Lucidity Sleep Psychiatry.
Should be Empty:

Rows	Sleep apnea	Narcolepsy	Insomnia	Restless Leg Syndrome	Depression	Anxiety	Bipolar Disorder	Other psychiatric disorder (list in comments)	Unknown/Not applicable
Father
Mother
Sister
Brother
Grandparents
Children

Rows	0 = Disagree	1	2	3	4	5	6	7 = Agree
My motivation is lower when I am fatigued.
Exercise brings on my fatigue.
I am easily fatigued
Fatigue interferes with my physical functioning.
Fatigue causes frequent problems for me.
My fatigue prevents sustained physical functioning.
Fatigue interferes with carrying out certain duties and responsibilities.
Fatigue is among my three most disabling symptoms. Fatigue interferes with my work, family, or social life.

Rows	None	Mild	Moderate	Severe	Very Severe
Difficulty falling asleep
Difficulty staying asleep
Problems waking too early

Rows	Not at all	A little	Somewhat	Much	Very Much
How NOTICEABLE to others do you think your sleep problem is in terms of impairing your quality of life?
How WORRIED / DISTRESSED are you about your current sleep problem?
What extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

BACKGROUND QUESTIONNAIRE

Epworth Sleepiness Scale

Fatigue Severity Scale (FSS) of Sleep Disorders

Insomnia Severity Index