Post Home Sleep Study Questionnaire
Must be filled after you did the Home Sleep Study
Patient's Full Name
*
First Name
Middle Name
Last Name
Patient's Date Of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Date of Follow-up Visit
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When did you do the Home Sleep Study?
*
Put specific date of Home Sleep Study
What time did you go to sleep?
*
Hour Minutes
AM
PM
AM/PM Option
What time did you wake up?
*
Hour Minutes
AM
PM
AM/PM Option
How much time did it take for you to fall asleep?
*
15 mins, 30 mins, etc.
How many hours of sleep did you get?
*
How many times did you wake up while doing the Home Sleep Study?
*
How many times did you get out of bed while doing the Home Sleep Study?
*
Please Select
0
1
2
3
4
5
6
7
8
9
How was your sleep?
*
Very Sound
Sound
Restless
Very Restless
How was your sleep compared to normal?
*
Better
Same
Worse
Did you wear any oral appliance while doing the Home Sleep Study?
*
Yes
No
If yes, what type of oral appliance did you use?
Did you take any medication(s) to help you fall asleep?
*
Yes
No
If yes, what type of medication(s) did you take to help you fall asleep?
Did you encounter any problems/issues while doing the Home Sleep Study? If so, please briefly explain:
Patient's Full Name
*
First Name
Middle Name
Last Name
Patient's Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: