bhsleepcenter.com - SLEEP MEDICINE

Patient Sleep History Questionnaire
Please complete this brief questionnaire before your visit. Your responses will help us understand your sleep concerns and determine what further evaluation may be helpful.
1. Patient Information
Full name:
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Usual bedtime:
Usual wake-up time:
Average hours of sleep per night:
2. Main Reason for Your Visit
What is the main reason for your visit?

Other
3. Sleep-Related Symptoms
Please check all that apply.
How long have you had these symptoms?
Do you unintentionally fall asleep during the day?
4. Sleep Schedule and Habits
How long does it usually take you to fall asleep?
How often do you awaken during the night?
Do you nap during the day?
Do you use caffeine?
If yes, how many caffeinated drinks daily?
Do you use alcohol near bedtime?
5. Medical history
Have you been diagnosed with any of the following?

Other
6. Previous Sleep Evaluation or Treatment
Have you had a sleep study?
Approximate date and location:
Have you used any of the following?
If you use CPAP or BiPAP, are you currently using it regularly?
What difficulties, if any, do you have with your treatment?
7. Medications and Additional Concerns
Current medications, including sleep aids:
Medication allergies
If yes, please list medication allergies:
What is your primary goal for this visit?
Should be Empty:

Patient Sleep History Questionnaire

1. Patient Information

2. Main Reason for Your Visit

3. Sleep-Related Symptoms

4. Sleep Schedule and Habits

5. Medical history

6. Previous Sleep Evaluation or Treatment

7. Medications and Additional Concerns