ADULT SLEEP QUESTIONNAIRE

ADULT SLEEP QUESTIONNAIRE
Patient Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Age
Date

MonthDayYear
Date

Patient Sleepiness Scale

	Yes	No
1. I have been told I stop breathing while asleep (8 points)
2. I have fallen asleep or nodded off while driving (6 points)
3. I've woken up with S.O.B/gasping or heart racing (6 points)
4. I feel excessively sleepy or fatigued during the day (4 points)
5. I snore or have been told I snore (4 points)
6. I have had weight gain and found difficult to lose (4 points)
7. I have been diagnosed with high blood pressure (4 points)
8. It takes me less than 10 minutes to fall asleep (4 points)
9. I wake up more than 1 time per night (4 points)
10. I wake up with headaches (4 points)

Additional comments
Total points

Health History (signs and symptoms): Check all that apply

	Experiencing
Insomnia
Diabetes
Depression
Mood Disorder
Wakes up with Dry Mouth
Grind Teeth
Brain Injury
Hypertension
Memory Loss
Family history of OSA/Snoring
Claustrophobia
History of stroke or Ischemic heart disease

Height
Weight
BMI
Current Medications
I authorize this practice to release any medical information for the purpose of coordinating care

Clear
Date

MonthDayYear
Date
East Hampton

87 Newtown Lane
East Hampton, NY 11937

(631) 502-4806
Riverhead

235 Osborn Avenue
Riverhead, NY 11901

(631) 705-8956
Should be Empty: