premierlungandsleep.com - Sleep Intake Form

Sleep Intake Packet
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Section A — Main Sleep Concern
1. What is your main sleep complaint?
2. How long has this been a problem?
3. Were there any events (weight gain, stress, illness, etc.) associated with onset?
4. Have you had a sleep study or home screen? When/Where?
5. Have you used CPAP/BiPAP? If so, how long? Pressure setting? Mask?
Section B — Epworth Sleepiness Scale (ESS)

Select the most appropriate number for each situation: 0 = never, 3 = high chance of dozing.
1. Sitting and reading

0

1

2

3

0 is Never, 3 is High chance of dozing
2. Watching television

0

1

2

3

0 is Never, 3 is High chance of dozing
3. Sitting inactive in public

0

1

2

3

0 is Never, 3 is High chance of dozing
4. Passenger in car for an hour

0

1

2

3

0 is Never, 3 is High chance of dozing
5. Lying down to rest in afternoon

0

1

2

3

0 is Never, 3 is High chance of dozing
6. Sitting and talking to someone

0

1

2

3

0 is Never, 3 is High chance of dozing
7. Sitting quietly after lunch (no alcohol)

0

1

2

3

0 is Never, 3 is High chance of dozing
8. In a car, stopped in traffic

0

1

2

3

0 is Never, 3 is High chance of dozing
Total:
Section C — STOP-Bang Questionnaire
Do you snore loudly (louder than talking or heard through doors)?
Do you often feel tired, fatigued, or sleepy during the daytime?
Has anyone observed you stop breathing during sleep?
Do you have or are you being treated for high blood pressure?
BMI more than 35 kg/m²?
Age over 50 years old?
Neck circumference > 40 cm / 16 in?
Male gender?
Section D — Restless Legs Syndrome (RLS) Questionnaire
Do you have an urge to move your legs, usually accompanied by uncomfortable sensations?
Do these begin or worsen during periods of rest or inactivity?
Do these begin or worsen during periods of rest or inactivity?
Are these partially or totally relieved by movement (walking, stretching)?
Are these worse in the evening or night than during the day?
Section E — Additional Sleep Symptoms (0–4 scale)

Select one number per line if applies: 0= Never 1= Sometimes 2= Often 3 = Always
Sleepy or dozing when driving

0

1

2

3

0 is Never, 3 is Always
Sleepy at work

0

1

2

3

0 is Never, 3 is Always
Take intentional naps

0

1

2

3

0 is Never, 3 is Always
Feel unable to move (paralyzed) when falling asleep

0

1

2

3

0 is Never, 3 is Always
Suddenly awaken choking or gasping

0

1

2

3

0 is Never, 3 is Always
Grind teeth

0

1

2

3

0 is Never, 3 is Always
Grind teeth

0

1

2

3

0 is Never, 3 is Always
Hold breath or told you stop breathing

0

1

2

3

0 is Never, 3 is Always
Hold breath or told you stop breathing

0

1

2

3

0 is Never, 3 is Always
Short periods of muscle weakness, esp. with laughter/excitement

0

1

2

3

0 is Never, 3 is Always
Need sleeping pill (Rx or OTC) to fall asleep

0

1

2

3

0 is Never, 3 is Always
Nightmares

0

1

2

3

0 is Never, 3 is Always
Uncomfortable/restless leg sensations relieved by moving

0

1

2

3

0 is Never, 3 is Always
Toss and turn / restless sleep

0

1

2

3

0 is Never, 3 is Always
Walk or talk in your sleep

0

1

2

3

0 is Never, 3 is Always
Snore

0

1

2

3

0 is Never, 3 is Always
Vivid dream‑like episodes when falling asleep

0

1

2

3

0 is Never, 3 is Always
Awaken with heartburn or acid reflux

0

1

2

3

0 is Never, 3 is Always
Wake with dry mouth

0

1

2

3

0 is Never, 3 is Always
Morning headaches

0

1

2

3

0 is Never, 3 is Always
Move about or aggressive behaviors while asleep / on awakening

0

1

2

3

0 is Never, 3 is Always
Use alcohol to fall asleep

0

1

2

3

0 is Never, 3 is Always
Use sleeping pills or OTC aids nightly > 3 weeks

0

1

2

3

0 is Never, 3 is Always
Lie awake > 30 minutes unable to fall asleep or return to sleep

0

1

2

3

0 is Never, 3 is Always
Dread going to bed because you feel you will not fall asleep

0

1

2

3

0 is Never, 3 is Always
Overall sleep quality (self‑rating)

0

1

2

3

0 is Never, 3 is Always
Section F — Sleep Habits
1. Bedtime weekdays/weekends:
2. How long to fall asleep?
3 What is your body position while you are sleeping?

Left:   e.g. 20%   %
Right:   e.g. 20% %
Back:  e.g. 40%   %,
Stomach:  e.g. 20% %
4a- How many times do you wake up at night?
4b- How long do stay awake each awakening?
4c- What reason do you have these night time awakening’s?
4c. Reason?
5. Wake time weekdays/weekends:
6. Hours of sleep:
7. How do you feel in morning?
8. Function best:
Morning
Afternoon
Evening
Section G — Medical History
Please outline your medical history: Do you have or have ever been told you have:
1. Your weight?
Your height?
2. Do you smoke?
If yes, how long?
How much? ____/ day
3. Do you drink alcohol?
If yes, how long?
How many drinks? ____/ day/wk/mo
4. Do you drink energy drinks, coffee, tea or soda
How many drinks? ____/ day/wk/mo
Section H — Bed Partner Observations

TO BE COMPLETED BY BED PARTNER
Check any of the following behaviors that you have observed the patient doing while asleep:
How long have you been aware of the sleep behaviors that you have checked above?
Describe the behaviors checked above in detail. Include the description of activity, time it occurs, frequency during the night and whether it happens every night.
Any additional comments:
Should be Empty:

Sleep Intake Packet

Section A — Main Sleep Concern

Section B — Epworth Sleepiness Scale (ESS)

Section C — STOP-Bang Questionnaire

Section D — Restless Legs Syndrome (RLS) Questionnaire

Section E — Additional Sleep Symptoms (0–4 scale)

Section F — Sleep Habits

Section G — Medical History

Section H — Bed Partner Observations