United Sleep & Respiratory Center

Sleep Consultation Form
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Your age
Your gender

FemaleMale
Your job title
Do you do shift work or work during the night?

YesNoDoes Not Apply
Do you have an exercise routine?

YesNo
How often do you exercise

DailyA few days in a weekOnce a weekA few days in a monthRarelyOther
Do you smoke?

YesNo
Indicate your daily usage of tobacco products
Alcoholic beverages consumption

ConstantlyOnce a weekMore than once a weekA few days in a monthOnly in an events or special daysRarelyNever
Indicate the daily consumption of caffeinated beverages (in cups)
Epworth Sleepiness Scale

How likely are you to nod 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.Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can. Use the following scale to choose the most appropriate number for each situation.
Sitting and reading:

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
Watching TV:

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
Sitting, inactive, in a public place(e.g., in a meeting, theater, ordinner event):

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
As a passenger in a car for anhour or more without stoppingfor a break

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
Lying down to rest whencircumstances permit:

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
Sitting and talking to someone:

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
Sitting quietly after a meal without alcohol:

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
In a car, while stopped for a few minutes in traffic or at a light:

Would never nod off (0)Slight Chance of nodding off (1)Moderate chance of nodding off (2)High chance of nodding off (3)
Sleep Routine
What time do you go to bed?

Hour Minutes

AM/PM Option
What time do you get out of bed?

Hour Minutes

AM/PM Option
Once in bed how long does it take to fall asleep (in minutes)?
How long does it typically take until you are fully awake (in minutes)?
Average hours of sleep per night
Once asleep, how many times do you wake up?
Are your bed and bedroom comfortable, dark, and silent?

YesNo
Describe your sleeping environment
Do you fall asleep somewhere except in your own bed?

UsuallyOftenRarelyNever
How often do you take naps?

DailyA few days in a weekRarelyNever
Who do you live or sleep with?
Sleep Issues and Behaviours
When trying to fall asleep, check all that you experience

Trouble staying asleepDifficulty falling asleepRepeated awakeningsWaking up too earlySnoring or trouble breathingChoking or gasping for airDry mouthSleep talkingSleep walkingBody jerksKept awake because of a partnerOther
When waking up, check all that you experience

Coughing or chokingShortness of breathIrregular/rapid heartbeatStomach acid tasteHeartburnDry mouthHeadacheSadness, stress or anxietyOther
During the day when you want to be alert and awake, check all that you experience

Feeling tired after a full-night sleepStruggling to stay awakeDifficulty in concentratingTrouble rememberingDozing offAvoiding social situationsSadness, stress or anxietySudden muscular weakness with strong emotionDaytime sleepinessOther
Medical History
List your current or past health problems
Specify any past surgeries or hospitalizations
Your medications information
Did you experience any allergies, side effects, or other adverse reactions to the medication?

YesNo
Provide detailed information about any allergies, adverse reactions or side effects
Any thing else you want to add
Your Signature
I confirm that the above information is correct to the best of my knowledge. I will take the responsibility to inform the consultant of any changes to my health or any of the above information.
Signature

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Sleep Consultation Form

Personal Information

Epworth Sleepiness Scale

Sleep Routine

Sleep Issues and Behaviours

Medical History

Your Signature