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