SLEEP EXAM
How do you sleep?
Patient Name:
Date:
-
Month
-
Day
Year
Date
Pillow
1. How old is your pillow?
Months 1-5
6-12
1 year
2 year
3 years
4 years
5 years
Or
2. How do you like your pillow? Thickness of pillow is:
Thin
Medium
Thick
3. What kind of pillow do you have?
Water
Memory foam
Feather
Air
Foam
Other
4. What brand of pillow do you own?
5. Do you like your pillow?
Yes
No
Sometimes
6. Do you wake up with:
Headaches
Neck pain/stiffness
Mid back pain
Low back pain
Bed
7. What type of bed Brand do you own?
8. How old is your bed?
9. What is the size of your bed?
King
Queen
Full
Twin
Memory Foam?
Yes
No
Pillow top?
Yes
No
What is the thickness of the Pillow top in inches?
2-3
3-4
4-5
5-6
Is it an Air Bed?
Yes
No
What is your sleep no #
10. Do you rotate your bed?
Yes
No
11. Can the bed be flipped?
Yes
No
Do you flip your bed?
Yes
No
12. Does your bed sag or indent?
13. Do you have an of these in your bed?
Animal
Child
Both
14. Do you have a partner that sleeps with you?
Yes
No
15. Do you
face your partner
or face away
Are you
next another
or away
16. How many hours/per night do you sleep?
3-4
4-5
5-6
6-7
7-8
8-9
10 or more
17. Do you sweat in your sleep?
Yes
No
Sometimes
If so do you throw off the covers?
18.
Females:
Are you going through Menopause?
19. What position do you feel you sleep in most thru the night?
Back
Side
Both
Stomach
20. Do you stay in the same position all night?
Yes
No
21. Which side do you sleep or lay on more?
Right side
Left side
22. Do you have a fan on in your bedroom?
Do you have a air conditioner on in your bedroom?
23. Do you have a CPAP machine
Do you have sleep apnea
Do you snore
24. Do you use a sleep monitor to monitor your sleep patterns (example fit bit)
Yes
No
25. What side of bed do you sleep on? (see diagram below)
Left
Middle
Right
Mark on the diagram what side/part of the bed you lay on:
Additional Questions:
Submit
Should be Empty: