Sleep Intake Form

Parham Gharagozlou MD Inc.

HealthySleepCare.com
3101 Clayton Rd., Concord, CA 94519

Sleep Intake Questions
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sleep Wake cycle
During work days what time do you generally go to bed to sleep?

Hour Minutes

AM/PM Option
During the off days what time do you generally go to bed to sleep?

Hour Minutes

AM/PM Option
During work days what time to you wake up?

Hour Minutes

AM/PM Option
During off days what time do you wake up?

Hour Minutes

AM/PM Option
In average, how many minutes does it take that you fall asleep after going to bed?
Minutes
Do you toss and turn in sleep?
Do you have long awakening in the middle of the night?
Do you have early morning awakening?
Do you follow a regular sleep-wake schedule?
How many minutes is your normal commute to work?
Minutes
How loud do you snore? ( zero for none)

0

1

2

3

4

5

6

7

8

9

0 is None, 9 is Very loud
Have you been told that you stop breathing?
Do you have choking or gasping in the sleep?

What are your chances to doze off during bellow activities

Do you have any of bellow symptoms?

Rows	Yes	No
Talking in sleep
Walking in sleep
Enacting your dreams in sleep
Eating or drinking in sleep or middle of night
Vivid dreaming
Muscle weakness after laughter or anger
Hallucination right before or after sleep
Inability to move after waking up
Leg discomfort during night that gets better with moving the legs?
Do you feel such leg discomfort interferes with your sleep?
Do you feel refreshed when you wake up?
Do you get sleepy during day time?
Do you regularly take naps?

Type a question

Rows	Yes	No
Do you have preformance problems at work/school?
Do you have interpersonal or relationship problems?

Do you have any of these symptoms?

Rows	Yes	No
Significant weight changes in 6 month
Day time fatigue
Morning headaches
Dry mouth or stuffy nose in the morning
Morning hoarseness
post nasal secretions
waking up confused
kicking or jerking legs in sleep
Violent behavior in sleep
Irritability
Depressed mood
Anxiety
Problem with concentration
Problem with memory
Nighmares
Audible breathing or breathing problem through nose
Sweating in the night
Heart pounding in the night
Too much coughing in the night
Feeling acid reflux in the night
Going to urinate 3 or more times in the night

Sleep Wake cycle