United Sleep Website Form

Sleep Consultation Form
Personal Information
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
What is the reason for your sleep evaluation?
Have you had a sleep problem in the past?
What treatments were tried?
Please provide your weight and height

WeightHeight
Excessive Sleepiness: (Do you feel excessively sleepy during the daytime? If yes, how long? Is this a result of your sleep?)
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.
Use the following scale: 0 = would never doze 1 = slight chance 2 = moderate chance 3 = high chance of dozing
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)
Have you ever had an unexplained lapse of consciousness while driving? (Reportable to Health Dept)
Have you felt sudden muscle weakness when you laughed, got angry, surprised?
Have you had hallucination or dreams apart from sleep?
Have you ever had an unexplained lapse of consciousness while driving? (Reportable to Health Dept)
Do you Snore?

NeverOccasionallyFrequentlyAlways
Please circle “loudness” rating which best describes your SNORING
Patients Rating

012345678910
Bed Partner Rating

012345678910
With your snoring, do you have any episodes of:
Chocking/Gasping

YesNo
Awakenings

YesNo
Episodes of stopped breathing

YesNo
A partner noting that you stopped breathing (OBSERVED APNEA)

YesNo
Morning headaches

YesNo
SLEEP SCHEDULE AND SLEEP HYGIENE
What time do you usually go to bed and wake up on weekdays?
Do you keep a regular sleep/wake schedule?

YesNo
Do you nap during the day

YesNo
Average length of nap?
Do you read in bed?

YesNo
Do you worry in bed?

YesNo
Do you currently do shift or night work?

YesNo
What hours?
Have you done shift work or night work in the past?

YesNo
If you do shift work or night work, do you have trouble sleeping when you do shift work? Yes/No

YesNo
If you could set your own schedule, what time would you go to bed and when would you get up?
Insomnia
Do you often have trouble getting to sleep? How long does it take?

YesNo
Do you wake up during the night? How many times per night you wake up?

YesNo
Do you have prolonged periods when you awaken and are unable to get back to sleep?1

YesNo
Do you wake too early?

YesNo
Do you check the clock when you are unable to sleep?

YesNo
MOVEMENT
Do you have restless legs at night?

YesNo
Do you have restless legs at night?

YesNo
PARASOMNIAS
Do you have nightmares or terrors?

YesNo
Did you wet your bed as a child?

YesNo
Do you grind your teeth at night?

YesNo
Do you sleepwalk?

YesNo
Medical History
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
Please list the medications you are taking (cosage, how often, condition/reason)
Do you smoke or use tobacco?

YesNo
Do you use caffeine?

YesNo
How many servings per day?

1234More
Do you use recreational drugs?

YesNo
Recreational drugs
Family and Medical History
Do members of your family have any sleep problems?

YesNo
If yes, what problems?
Have you had surgery on your nose or throat?

YesNo
Do you have any of the following:
High blood pressure

YesNo
Low Blood pressure

YesNo
Lung disease

YesNo
Kidney disease

YesNo
Diabetes

YesNo
Stroke

YesNo
Seizures/Head trauma

YesNo
Impaired Cognition

YesNo
Depression/Anxiety

YesNo
Pneumonia

YesNo
Tuberculosis

YesNo
Heart disease

YesNo
Previous surgeries
Psychiatric/Psychologic Therapy
Have you ever had a sleep study before?

YesNo
Which Sleep Center
Are you currently being treated for Sleep Apnea?

YesNo
What is the Treatment?
Are you on CPAP/Bilevel or Oxygen?

YesNo
What Therapy and Settings/LPM?
What Durable Medical Equipment Company Provided your Equipment?
Should be Empty:

Sleep Consultation Form

Personal Information

Epworth Sleepiness Scale

Please circle “loudness” rating which best describes your SNORING

With your snoring, do you have any episodes of:

SLEEP SCHEDULE AND SLEEP HYGIENE

Insomnia

MOVEMENT

PARASOMNIAS

Medical History

Family and Medical History