Sleep History Questions

Do you have any difficulty falling asleep?
Are you having difficulty sleeping throughout the night?
How often do you waken?
How long are you awake?
Do you have any pain, discomfort, or shortness of breath during the night?
What prevents you from falling back to sleep?
Have you or anyone else ever noticed that you snore loudly or stop breathing in your sleep?
Are you sleepy or tired during the day?
Do you have headaches when you wake up?
Do you fall asleep during the day?
Do you experience daytime sleepiness?
Do you suffer from daytime fatigue?
Have you fallen asleep while driving?
Do you have high blood pressure?
Do you take blood pressure medication?
Do you have an irregular heartbeat?
Do you suffer from depression?
Do you drink alcoholic beverages?
Do you take sedative type medication?
Do you have restless legs while lying in bed?
Do you have disrupted sleep?
Do you urinate frequently during the night?
Do you snore heavily at night?
Has your spouse seen you obstruct during sleep?
Do you kick or poke your partner while sleeping?
How long does it take for you to fall asleep?
How many times a night do you awaken?
How long do the awakenings last?

SLEEP TIME

How many hours do you usually sleep?
(do not include hours spent in bed awake)
How many hours does it take to make you feel rested?
How many daytime naps do you take per week?

SLEEP QUALITY

Do you feel unrefreshed and still sleepy upon awakening?
How long does it take to fully awaken in the morning?
In the daytime, are you chronically sleepy, fatigued or tired?

SLEEP AND BREATHING

1. Do you snore? YES NO
2. Is your snoring broken by hesitations, gasps and snorts? YES NO
3. Are the hesitations long enough to frighten your sleep partner? YES NO
4. Has your snoring driven your bed partner from the bedroom? YES NO
5. Do you awaken with a dry mouth? YES NO
6. Do you awaken with headaches?

E. INSOMNIA

1. Do you have trouble falling or staying asleep? YES NO
2. Do you worry about being able to fall asleep on time? YES NO
3. Do you feel sleepy prior to getting into bed? YES NO
4. Does your mind race with thoughts when lying awake? YES NO
5. Do daytime worries keep you awake at night? YES NO
6. Does pain disturb your sleep? YES NO
7. Does heat, cold, hunger or thirst disturb your sleep? YES NO
8. Is your insomnia the primary reason your life is in disarray? YES NO
9. Do you rely on a sleeping medication? YES NO
10. Do you watch TV, read, or work in bed? YES NO
11. Do you frequently travel across 2 or more time zones? YES NO

F. SLEEP DISTURBANCES

1. Do you experience unpleasant leg sensations at bedtime? YES NO
2. Do you kick or jerk your legs and/or arms during sleep? YES NO
3. Do you have sweats or awaken from sleep feeling flushed? YES NO
4. Do you awaken with a bitter or acid taste? YES NO
5. Do you frequently have nightmares or vivid dreams? YES NO
6. Do you grind your teeth or have bitten your cheek during sleep? YES NO
7. Have you ever walked or talked in your sleep? YES NO
8. Have you ever been unable to move for a few moments after awakening? YES NO
9. Have you ever seen or felt things from your dreams after awakening? YES NO
10. Have you ever experienced weakness when laughing or angry? YES NO
11. Have you ever had unusual movements or behaviors during sleep? YES NO
G. PERSONAL HABITS

1. Do you use tobacco now or have you in the past? YES NO
a. If yes, how many per day and for how many years? b. If yes, what time of day is your last use? 2. Do you drink alcohol? YES NO a. If yes, how many drinks? _______ per day / per week / per month (circle one). b. If yes, what time of day is your last drink? 3. How many caffeinated beverages do you drink per day? a. If yes, what time of day is your last drink? Bed Partner Questionnaire Does your bed partnerТs sleep problems disrupt your sleep? ?? Never ?? Occasionally ?? Often Explain: Has your bed partnerТs mood, memory, concentration, or personality deteriorated or changed? ?? Yes ?? No If yes, please explain: How much stress does your bed partner currently have? ?? 1 (Light) ?? 2 ?? 3(A Lot) ?? Unknown Is you bed partner restless during sleep? ?? Never ?? Occasionally ?? Often ?? Unknown Mark any positions your bed partner sleeps in: ?? Back ?? Side ?? Stomach Does your bed partner snore? ?? Never ?? Occasionally ?? Often ?? Unknown If they snore, please mark the positions they snore in: ?? Back ?? Side ?? Stomach How loud is his/her snoring? ?? 1 (Light) ?? 2 ?? 3 ?? 4 ?? 5 ( Loud) Does your bed partner do any of the following in his/her sleep? (Please mark all that apply) ?? Gagging ?? Choking ?? Snorting ?? Gasping ?? Teeth Grinding ?? Kicking their feet Never Occasionally Often Unknown Does you bed partner take naps during the day? Does your partner stop breathing in his/her sleep? Does your bed partner fall asleep when driving? Does he/she fall asleep without warning? Does your bed partner kick their legs while sleeping? Does your bed partner mumble, talk, or yell during sleep? Does your bed partner awaken during the night? ?? Never ?? Occasionally ?? Often ?? Unknown If they awaken, how long does it take them to get back to sleep? Hrs: Mins: ?? Unknown Do you know why he/she awakens? ?? Yes ?? No If yes, Why? How often have you observed this personТs sleep? Has this person fallen asleep during normal daytime activities or in dangerous situations? If yes, explain: What behaviors have you observed in this person while he or she was asleep? Check all that apply. o Light snoring o Limb movement every 10-20 seconds o Teeth grinding o Loud snoring o Awakening with pain o Sitting up in bed o Occasional loud snorts o Leg or arm twitching o Head rocking/banging o Choking o Leg kicking o Sleepwalking o Pauses in breathing o Shaking or rocking o Bedwetting o Becoming very rigid o Doing an unusual activity o Other 1. What is your height? inches 2. What is your weight? pounds A. Has your weight changed in the last year? (+) (-) pounds B. Has your weight changed in the last 4 months? (+) (-) pounds 3. What is your neck size? inches 4. Are you in good health as far as you know? ?? Yes ?? No 5. Give the year of your last physical examination. Abnormalities, if any 6. Have you had any health problems in these areas? TYPE OF PROBLEM DATES PHYSICIAN, CLINIC OR HOSPITAL MENTAL HEALTH, DEPRESSION HEAD OR NERVOUS SYSTEM EARS, EYES, NOSE, THROAT, MOUTH OR SINUSES HEART, CIRCULATION, BLOOD PRESSURE 2 BREATHING, LUNGS STOMACH, DIGESTIVE URINE, KIDNEY OR SEXUAL OTHER (E.G., DIABETES, HORMONE ABNORMALITIES, HYPOGLYCEMIA) SURGICAL OPERATIONS 7. How much of these beverages do you consume? Coffee Cups/day Cups after 6:00 p.m. Decaffeinated Coffee Cups/day Cups after 6:00 p.m. Tea Cups/day Cups after 6:00 p.m. Carbonated Drinks Cups/day Cups after 6:00 p.m. Beer, Wine, Liquor Cups/day Cups after 6:00 p.m. 8. How many cigarettes, cigars or pipe-fulls of tobacco do you smoke? day 9. Do you smoke marijuana? ?? Yes ?? No If yes, how often? 10. Do you use non-prescription drugs? ?? Yes ?? No Describe which and how much of each 11. Do you take any prescribed medication, either regularly or intermittently? ?? Yes ?? No Name of Medication Dose How Many Times Per Day For What Reason Length of times used Prescribing Physician 12. Name and address of personal or family physician 3 13. Use space below for any additional comments you may wish to make about your health, intake of drugs, medicines or alcohol. 14. Family Health History Living - Deceased Age If deceased, what age Cause of death Medical Problems Father Mother Siblings (Indicate brother or sister) 15. Are you on home oxygen? ?? Yes ?? No If yes, what liter flow are you on? What type of apparatus do you use? (Nasal cannula, face mask, etc.)? EAST JEFFERSON GENERAL HOSPITAL SLEEP LABORATORY SLEEP HISTORY 4 NAME: DATE: 1. Briefly describe your sleep problem: 2. Why are you being seen in the Sleep Lab now? 3. How long have you had this problem? years? 4. How does this affect your life and daily activities? 5. How serious a problem is this for you? ?? Not at all serious ?? Moderately serious ?? Very Serious 6. Have you had any previous evaluations, examinations, or treatment for this sleep problem or any other problem with your sleep? ?? Yes ?? No If so, briefly describe the evaluation, treatment and results below (include overnight pulse oximetry). 7. What was your sleep like as a child? 8. Did you sleep more, the same or less than other children? 9. When do you actually attempt to go to sleep and get out of bed weekdays? Go to bed A.M/P.M. Get up A.M./P.M. 10. When do you actually attempt to go to sleep and get out of bed weekends? Go to bed A.M./P.M. Get up A.M./P.M. 11. What is the average amount of sleep you need to feel alert and energetic? 5 12. On the average, how long does it take you to fall asleep at night after you turn out your bedroom lights? minutes. 13. Has there been a recent change? ?? Yes ?? No If yes, describe briefly: 14. What do you do just prior to turning out the lights and attempting to go to sleep (e.g., reading, T.V., bath, etc.)? 15. Do you have a regular bed partner? ?? Yes ?? No 16. On the average, how many times do you wake up during the night? 17. Average number of minutes of each awakening. 18. Do you wake up too early in the morning and have trouble returning to sleep? ?? Yes ?? No 19. How do you ordinarily awaken? ?? Spontaneously ?? Alarm Clock ?? Other 20. On the average, how long do you actually sleep at night? Hours Minutes 21. Is it difficult for you to awaken and get out of bed after sleeping? ?? Yes ?? No 22. Do you nap or return to bed after arising? ?? Yes ?? No If yes, how many times per day? Average length of sleep per nap Hours Minutes 23. Do you usually feel physically tired (separate from sleepy) during the day? ?? Yes ?? No 24. Are you bothered by sleepiness during the day? ?? Yes ?? No Describe when and the extent 25. Do you feel that you get too much sleep at night? ?? Yes ?? No 26. Do you feel that you get too little sleep at night? ?? Yes ?? No 27. Do you find yourself falling asleep at inappropriate times? ?? Yes ?? No 6 If yes, describe 28. How long does the sleep episode last? Hours Minutes. 29. Do you feel rested or refreshed after the sleep episode? ?? Yes ?? No 30. Have you ever (a) fallen suddenly? ?? Yes ?? No (b) experienced sudden bodily weakness? ?? Yes ?? No 31. Have you ever experienced a sense of weakness or paralysis upon: A. Going to sleep? ?? Yes ?? No B. How often does this occur? times/week 32. Have you ever experienced seeing things or hearing voices or noises that may not be? A. Upon going to sleep? ?? Yes ?? No B. During the night? ?? Yes ?? No C. Upon awakening ? ?? Yes ?? No D. During the day? ?? Yes ?? No 33. Do you ever feel that you go into a dream immediately at the onset of sleep at night or when you nap? ?? Yes ?? No If yes, briefly describe 34. Have you been told that you snore while asleep? ?? Yes ?? No Does this occur continuously through the night? ?? Yes ?? No 35. Is the snoring regular? ?? Yes ?? No Is the snoring interrupted by gasping or choking? ?? Yes ?? No 36. Does the snoring disturb anyone? A bed partner (or someone in the same bedroom)? ?? Yes ?? No Someone in another room? ?? Yes ?? No Sleep in house or apartment alone? ?? Yes ?? No 37. Has anyone ever told you that your arms or legs jerk or twitch while you are apparently asleep? ?? Yes ?? No If yes, how often during the night does this occur? times/night. How many nights per week does this occur? nights/week. At what age did this first come to your attention? years old. Does this seem to awaken you from sleep? ?? Yes ?? No 38. While lying in bed before sleep or upon awakening, have you ever experienced a restlessness of legs, Уnervous legsФ or Уcreeping, drawingФ sensation in legs? ?? Yes ?? No 7 How often does this occur? times/week. Does anything relieve the situation (e.g, getting out of bed, taking medication, massage, etc.)? ?? Yes ?? No If yes, what What age did you first experience this? years old. 39. At what time of day do you feel most alert and function at your best? A.M./P.M. 40. Do you follow a fairly regular bedtime schedule? ?? Yes ?? No If no, describe 41. How much does changing your bedtime affect your sleep? ?? Very Little ?? Somewhat ?? Much 42. Do you now or have you ever done any of the following: (Check all that apply) Times/Week Age It Began Last Occurred Treatment Talk while apparently asleep Sleepwalk Grind teeth while apparently asleep Wet the bed during sleep Wake up screaming or seemingly afraid in the first 2 1/2 hours of sleep Have disturbing dreams Have chest pain at night Have wheezing at night Have unusual movements while apparently asleep Awaken during the night with headaches Have recurrent dreams 43. Have you ever realized that you have done something without being aware of it at the time or not knowing how you came to be in a certain place? ?? Yes ?? No 8 If yes, please describe briefly 44. Has anyone in your family ever had any sleep problems? ?? Yes ?? No If yes, please list the type of problem (e.g., trouble getting to sleep, bed wetting, etc.) and relationship to you. Type of Problem Relationship Treatment 45. Have you used any medication (prescribed or otherwise) to help your sleep problem? ?? Yes ?? No If yes, list below: Name Amount Frequency When Used Helpful Prescribing Physician 7. At what time do you usually go to bed? ________ ________ 8. At what time do you usually get up? ________ ________ 9. How much does your sleep vary?. . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 10. How often do you usually awaken during the night? ____________Times 11. How many hours of sleep do you usually get during the night? ______Hours 12. Do you fall asleep watching TV?. . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 13. Do you fall asleep reading the newspaper. . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 14. Do you ever get extremely sleepy during driving?. . . . . . . . . . . . . .1 2 3 4 5 15. Have you ever stopped driving due to excessive sleepiness?. . . . . ..1 2 3 4 5 16. Have you ever had an automobile accident due to sleepiness or falling asleep? Yes No More than once 17. Have you ever had a near automobile accident because of sleepiness?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ЕЕ Е.. . . . . .. .1 2 3 4 5 18. Do you fall asleep while talking to people?. . . . . . . . . . . . . ЕЕЕ . 1 2 3 4 5 19. Do you get particularly sleepy when you are inactive?. . . . ЕЕ . . . 1 2 3 4 5 20. Do you ever feel confused when you awaken from sleep?. . . . . Е... 1 2 3 4 5 21. Do you feel refreshed after a short (10-15 minute) nap?. . . . . . ЕЕ 1 2 3 4 5 22. Do other people tell you that you snore loudly?. . . . . . . . . . . .. . Е... 1 2 3 4 5 23. Does you sleepiness appear to be worse 3-4 times per day?. . . ЕЕ 1 2 3 4 5 24. Does your daytime sleepiness occur at fairly predictable intervals?. . 1 2 3 4 5 25. Do you wake up with morning headaches?. . . . . . . . . . . . . . . ЕЕ . .1 2 3 4 5 26. Do other people tell you that you have restless sleep?. . . . . . . . ЕЕ 1 2 3 4 5 27. Have other people noticed that you have become increasingly irritable or short-tempered?.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 28. Has your sexuality decreased lately?. . . . . . . .. . . . . . . . . . . . . . . Е...1 2 3 4 5 29. Do you have difficulty with your sexual functions? . . . . . . . . ЕЕ . 1 2 3 4 5 30. Do you find that your mind is not working as quickly or effectively as it used to?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 31. When you awaken in the morning, how long does it usually take for you to begin functioning normally? 0-15 min.. 15-30 min., over 30 min 32. Do you sweat a great deal at night?. . . . . . . . . . . . . . . . . . . ЕЕ. . . 1 2 3 4 5 33. When you are angry or laugh, do you feel weak, as though you may fall?. . . . ЕЕЕЕЕЕ. ЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕЕ... 1 2 3 4 5 34. Do other members of you family have sleepiness problems?. . ЕЕ.1 2 3 4 5 35. Do you have trouble getting to sleep at night?. . . . . . . . . . . . . . ЕЕ.1 2 3 4 5 36. Are you bothered by frequent awakenings during the night?. . . ЕЕ.1 2 3 4 5 37. Do your ankles swell?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ЕЕ. .1 2 3 4 5 At sleep onset, how often do you: 38. Have thoughts racing through your mind?. . . . . . . . . . . . . . . . . . . . .. 1 2 3 4 5 39. Feel afraid of not being able to fall asleep?. . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 40. Experience restless legs (crawling or aching feelings, and inability to keep legs still?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 41. Experience any kind of pain of physical discomfort?. .. . . . . . . . . . . .1 2 3 4 5 42. How long does it usually take you to fall asleep? . . . . . . . . .______________ During the night, how often do you: 43. Wake up choking, unable to breathe?. . . . . . . . . .. . . . . . . . . . . . . . . .1 2 3 4 5 44. Wake up because of heartburn?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 45. Notice that your heart was pounding, beating rapidly, or irregularly?.1 2 3 4 5 46. Wake up to urinate?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 1 2 3 4 5 47. Have restless, disturbed sleep?. . . Е. . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 48. Wake up due to nasal congestion?. . . . . . . . . . . . . . . . . . . . . . . . . . . ..1 2 3 4 5 49. Experience asthma symptoms?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 50. Have you ever been told that you hold your breath in your sleep?.. . 1 2 3 4 5 51. How often do you have unusual difficulty in waking up?. . . . . . . . . . 1 2 3 4 5 52. How often do you wake up more tired than when you went to bed?. .1 2 3 4 5 53. If you take a nap, how long do you usually sleep?. . . . .. ._____________ 54. How often do you take a nap during the day?. . . . . . . . . . .____________ 55. Do you usually feel refreshed after a nap?. . . . . . . . . . . Yes No 56. How often do you experience vivid dream-like images while falling asleep Or awakening, or even while you felt you were awake?. . . Е. . . . . . 1 2 3 4 5 57. Have you ever fallen asleep at work?. . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 58. How great of a problem do you have with performance at work because of sleepiness?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 59. How often do you discover that you have performed a complex act such as driving a car to the wrong destination, and not remember how you did it?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 60. Do you think you are excessively sleepy during the daytime?. . . . . .1 2 3 4 5 Questions about your general health 61. What is your body weight: Now _________lbs., 6 months go_________lbs., 2 yrs. Ago_________lbs., when age 20_________lbs., when heaviest ever _________lbs. 62. Have you had a significant change in appetite during the past 6 months? Yes No Do you have any problems with: 63. Nasal congestion, obstruction, or discharge?. . .. . . . . . . . . . . . . Yes No 64. Swallowing?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 65. A lump or obstruction in the throat?. . . . . . . . . . . . . . . . . . . . .. Yes No Have you ever had problems with your: 66. Stomach?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 67. Liver?. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . Yes No 68. Kidneys?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 69. Bowels?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 70. Bladder?. . . . . . . ЕЕ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Have you ever had problems with: 71. Tumors? (cancer). . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Yes No 72. Tonsils or adenoids?. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . Yes No 73. Sinusitis or nasal polyps?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 74. Thyroid gland?. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Yes No 75. Low blood sugar (hypoglycemia)?. . . . . . . . . . . . . . . . . . . . . . . . Yes No 76. Sugar in your urine (diabetes)?. . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 77. High blood pressure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 78. Heart disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 79. Chest? (circle: Asthma, Bronchitis, Pneumonia). . . . . . . . . . . . . . Yes No 80. Have you ever had your tonsils or adenoids removed?. . . . . . . . Yes No 81. Have you ever had an operation on your nose?. . . . . . . . . . . . . . . Yes No How often do you get pains in your: 82. Neck, back, joints or muscles?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 83. Heart? (angina) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 84. Chest?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . .1 2 3 4 5 85. Abdomen?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 86. Other?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 87. Have you ever been knocked unconscious?. . . . . . . . . . . . . . . . . . . . ._______ 88. Have you ever had any head injuries?. . . . . . . . . .. . . . . . . . . . . . . . . ._______ How often do you: 89. Have swelling in your ankles?. . . . . . . . . . . . Е. .. . . . . . . . . . Е . . . 1 2 3 4 5 90. Suffer from numbness, pins and needles, in you arms or legs?... . . . . 1 2 3 4 5 91. Have headaches during the day?. . . . . . . . . . . . . . . . . . . . . . . . . .. . . .1 2 3 4 5 92. Suffer from dizzy spells?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 93. Have episodes of loss of consciousness or fainting?. . . . . . . . . . . . . . 1 2 3 4 5 94. Have convulsions, seizures, epilepsy?. . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 95. Have shortness of breath?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 96. Hold your breath or hyperventilate?. . . . . . . . . . . . . . . Е.... . . . . . . .1 2 3 4 5 97. Have heart flutters?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ЕЕ .. . . .1 2 3 4 5 98. Have allergies to food? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Е.... 1 2 3 4 5 99. Have allergies to medications? List______________________________________________________________ _________________________________________________________________ 100. Place a mark on the line somewhere between 0 (lowest) and 10 (highest) that Indicates your general level of well-being at the present time: 0 ------ 1 ------ 2 ------ 3 ------- 4 ------ 5 ------ 6 ------ 7 ------ 8 ------ 9------10 101. How much stress do you presently have? . . . . . . . . . . . . . . . . . 1 2 3 4 5 102. How long have you had your sleep problem .____________________ 103. Describe how you feel when you wake up in the morning?___________ ______________________________________________________________ _________ 104. Please list all current medications (including non-prescription medications) Name Dosage Per Day _______________________________ ______________________________ _______________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ ________________________________ ______________________________ 105. Past Medical History (Previous illnesses) Year of onset Name of illness ________________________________ ________________________ ________________________________ ________________________ ________________________________ ________________________ ________________________________ ________________________ ________________________________ ________________________ 106. Past Medical History (Previous injuries) Year of Injury Type of Injury ________________________________ _____________________________ ________________________________ _____________________________ ________________________________ _____________________________ ________________________________ _____________________________ ________________________________ _____________________________ 107. Previous hospital admissions (include surgical operations and psychiatric admissions) Month/Year Location Reason for admission _________________ _______________ ____________________________ _________________ _______________ ____________________________ _________________ _______________ ____________________________ 108. Previous sleep recordings or EEGТs: Month/Year Location Reason for admission ________________ _______________ ____________________________ ________________ _______________ ____________________________ How much of these fluids do you drink? In a 24 hr. period: Within 2 hrs. of bed During the night 109. Coffee? ________cups _________cups _______ cups 110. Tea? ________cups _________cups ________cups 111. Cola drinks? ________bottles _________bottles ________bottles 112. Some other drinks?___________________________________________________ How many alcoholic drinks do you have during a usual 24- hour period? Weekday Weekend 113. Bottles (cans) of beer? _____________ ______________ 114. Glasses of wine? _____________ ______________ 115. Shots of liquor? _____________ ______________ How often do you drink alcoholic beverages? 116. Within 2 hours of trying to go to sleep?. . .. . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 117. During the night?. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .1 2 3 4 5 118. In order to get to sleep?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 119. To steady your nerves?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 120. Do you consume less alcohol now than you did in the past?. . . . . . 1 2 3 4 5 How often have you: 121. Tried to quit... ЕЕ.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 122. Gotten sick from drinking alcoholic beverages?. . . . . . . . . . . . . . . .1 2 3 4 5 123. Had blackouts associated with alcoholic beverages?. . . . . . . .. . . . . 1 2 3 4 5 124. Had violent or overexcited behavior associated with drinking> . . . .1 2 3 4 5 Tobacco and street drugs: 125. How many years have you smoked? ___________Years How much tobacco do you smoke during a 24-hour period? The past Now 126. Packs of cigarettes? _____________ ______________ 127. Cigars? _____________ ______________ 128. Pipe (bowls)? _____________ ______________ How often do you smoke tobacco? 129. Within 2 hours of sleep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5 130. During the night. . . . . . . . . . . . . . . . . . . . . . . . . . ЕЕ. . . . . . . . . . .1 2 3 4 5 How often have you used any of the following to help you go to sleep? 131. Tobacco?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . 1 2 3 4 5 132. Marijuana?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 133. Narcotics?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 2 3 4 5 134. Do you take any medications to help you with your sleep? Е.. Yes No 135. Do you take any type of medication to help you with a problem with daytime sleepiness? . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 136. Have you ever had a prescription for sleeping medications? . Е Yes No Have you ever taken: 137. Insulin?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 138. Cardiac drugs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Yes No 139. Cancer chemotherapy?. . .. . . . . . . . . . . . . . . . . . . . . . . .. Yes No 140. Thyroid medication?. . . . .. . . . . . . . . . . . . . . . . . . . . . . .. Yes No 141. Sex hormones (testosterone, estrogen)?. . . . . . . . . . . . . . Yes No 142. Steroids (Cortisone, Predisone)?. . . . . . . . . . . . . . . . . .. . Yes No Occupation: 162. What is your present occupation? _______________________________ 163. Do you work variable shifts?_____________________________________ 164. How many hours per week do you work? __________________________ 165. What is your personal interpretation as to why you have your particular sleep/wake problems?___________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 5). Screening questions for PARASOMNIAS (or things that go УbumpФ in the night including REM behavior disorder and include disorders of sleep walking or sleep talking). A. Do you remember your dreams? B. Do you have nightmares? C. Are you told that you act out your dreams in nightmares by swinging your arms, legs, or by moving or yelling? If so, do they occur early or late during the sleep period? D. Have you hurt yourself or anyone else associated with these movements during the night? E. Have you been told that you sleepwalk? F. Do you sleep talk, and if so, can you be understood? Can people understand what you are saying? Also, if these events occur, do they occur in the first third of the night or in the latter third of the night? G. Have you been told that you arouse from sleep totally confused or are inconsolable? H. Have you awakened feeling panicked with your heart beating uncontrollably? I. Have you experienced uncoltrolled urination in your sleep either as a child or as an adult? J. Do you have a history of seizures? 6). Screening questions for INSOMNIA. A. Are you unable to fall asleep in 15 minutes or less? B. Do you wake up several times during the night and cannot get back to sleep? C. Do you wake up one or two hours early in the morning? D. Do you have thoughts racing through your mind while trying to fall asleep? E. Do you watch a clock while trying to sleep? F. Do you have anxiety which keeps you from sleeping? Screening questions for NARCOLEPSYЧ includes the uncomfortable urge to sleep during the day, especially during emotional events (feeling happy, sad, or mad). A. Do you feel your knees buckle or, your arms feel weak, or jaw drop when you are happy or sad? (cataplexy). B. Do you experience vivid dream-like episodes or scenes upon awakening or falling asleep that you canТt tell whether they are real or not? (hypnagogic hallucinations) C. Do you feel paralyzed when waking or falling asleep? (sleep paralysis). D. Do you have automatic behavior? For instance, while driving do you have periods when you go past certain exits and you are uncertain whether youТve done something only to find out that it was already done, or find yourself in places where you are not sure where you should be at? E. Do you have a history of head trauma or loss of consciousness? 4). Screening questions for PERIODIC LEG MOVEMENTS OF SLEEP. A. Do you have leg cramps at bedtime? B. Do you experience crawling and achy feelings in your legs during the day or night which makes you want to move them or walk them? C. Do you notice that these achy feelings in your legs are worse at night time? E. Have you been told that your legs or arms move every 20 seconds or so during the night? G. Do you have muscle tension which can disrupt sleep onset? H. Are you bothered by pain during the day or at night? I. Do you wake up feeling stiff in the morning or have sore, achy muscles? 6). Screening questions for BRUXISM. A. Do you have morning jaw pain? B. Do you grind your teeth during sleep? 7). SLEEP HYGIENE: It is also important to look at sleep hygiene issues. Ask them what time they go to bed and what time they usually awaken during the weekends as well as during the weekday. See if the time remains constant or not. 8). NOCTURNAL AWAKENINGS: How many times do you wake up during your sleep, and if so, what part of the night is it, and what are the usual causesЧto urinate, shortness of breath, heartburn, body-jerking, or not sure? 9). WORK SCHEDULE: Are they shift workers? Do they work swing shifts at work which means that their shift changes from one week to the next. Also, ask about experiences with travel especially jet lag, especially after traveling eastwardly. 10).CIRCADIAN RHYTHM: Ask them if they have trouble waking up in the morning and would rather stay up later (ie. 2-3 am) and sleep in until noon (Delayed Sleep PhaseЧmore common in adolescents). Ask if they go to bed at 8 pm only to find out that they wake up at 3 am (Advanced Phase SyndromeЧmore common in the elderly). 11).MEDICATIONS: Ask what medications they are taking or what surgeries have been done to try to help their sleep problem. 12).FAMILY HISTORY: Be sure to get a family history since narcolepsy runs in families.