• Sleep and Alertness Clinic Questionnaire

    Thank you for taking the time to fill out this questionnaire, please try to complete this questionnaire to the best of your ability.  The more details you provide you will help your doctor give the best treatment plans.  This questionnaire should take about 20 minutes to fill out.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Family physician information
  • Have you been for a sleep test previously?

  • Sleep Test Preparation

    To help us prepare for your sleep test, if arranged, please let us know the following:
  • Is your current weight greater than 350lbs?*
  • Do you have any skin allergies or sensitivies to:*
  • Do you have any accessibility/mobility needs? For example, do you use any of the following?*
  • Do you have a driver's license?*

  • Sleep Routine

  • Do you feel refreshed in the morning?
  • Do you feel tired during the day?
  • What position do you prefer to sleep in?

  • Napping

  • Are your naps refreshing for you?
  • Do you dream during your naps?

  • Apnea

  • Do you snore?
  • Do you wake up with a dry mouth?
  • Do you drool on your pillow?
  • Do you sweat at night?
  • Do you wake up with a headache?
  • Do you gasp for air at night?
  • Do you stop breathing at night?

  • Bruxism

  • Have you ever been told that you grind or clench your teeth?
  • Have you ever been provided with a mouth guard for this?
  • If you have been given a mouth guard, does it sit on the:
  • Are you currently using your mouth guard?

  • Narcolepsy

  • When laughing or if suddenly excited, do you suddenly lose muscle control or strength in your face, arms and/or legs?
  • On occasion, do you wake up soon after going to sleep or in the morning actually feeling paralyzed, unable to move or unable to talk, which lasts only a few seconds or minutes?
  • Are your dreams so real you cannot tell if you are asleep or awake?

  • Parasomnias

  • Do you talk in your sleep?
  • Do you grind your teeth when you sleep?
  • Do you sleepwalk?
  • Do you have frequent nightmares?
  • Do you experience episodes of extreme terror or screaming during sleep, yet have little or no recollection of the event?
  • While asleep, have you ever acted out a dream and injured yourself or bed partner?
  • Do you eat in your sleep? (This is not concerning dreams)
  • Have you ever initiated sexual activity with a bed partner while asleep?
  • Have you exhibited any unusual behaviour in your sleep?

  • RLS/PLMS

  • Have you experienced recurring unpleasant sensations or tingling in your legs while sitting or lying down?
  • If yes, how would you describe this sensation?
  • If these sensations or movements are present and you get up to walk, do they improve or disappear while you are walking?
  • If yes, do they get worse again when you stop walking?
  • Do your legs jump or move involuntarily while sitting or lying down?
  • If yes, do you think the sensations in your legs and these movements are connected?
  • If yes, do these involuntary movements occur only before you fall asleep?

  • Social History

  • Highest level of education?
  • Do you live in a:
  • Do you have a bed partner?
  • Do you have active thoughts about committing suicide?

  • Substances

  • On average, how much alcohol do you drink per week? (If less than 1 drink per week, write 0)
  • On average, how much caffeine do you take in each day? (If less than one, write 0)
  • Do you use marijuana?
  • If yes, what method(s) do you use?
  • If yes, what cannabinoids do you use?
  • If yes, do you use marijuana to help you sleep?
  • Street Drug Use: If yes, please select which ones you use below
  • Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
    Rows
  • Athens Insomnia Scale (This scale is intended to record your own assessment of any sleep difficulty you might have experienced. Check one for each statement below to indicate any difficulty, if it occurred at least three times per week during the last month)

  • Athens Insomnia Scale

  • Patient Health Questionnaire (PHQ-9)

  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
    Rows
  • If you indicated any problems on the above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

  • General Anxiety Disorder (GAD-7)

  • Over the last 2 weeks, how often have you been bothered by the following problems?
    Rows
  • Rows

  • If you scored 10 or above, you might want to consider one or more of the following:

    1. Discuss your symptoms with your doctor

    2. Contact a local mental health care provider

    Although these questions serve as a useful guide, only an appropriate licensed professional can make the diagnosis of Generalized Anxiety Disorder.

     

  • Thank you for completing the questionnaire. Please submit the questionnaire and a member of our team will be contacting you to schedule your appointment.

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