Munson Healthcare Sleep Disorders Center Patient Questionnaire

Patient Information

The answers to the following questions will help the provider better understand your medical history. Although every question may not apply to the problem that you have come to see the provider about, your answers will assist in developing a complete picture of your overall health.

Name: [text input]

Gender: [radio button: Male] [radio button: Female] [radio button: Other]

Phone: [phone input]

Age: [number input]

Marital Status: [radio button: single] [radio button: married] [radio button: divorced] [radio button: other]

Living situation: [radio button: self] [radio button: significant other] [radio button: family] [radio button: other]

Primary Care Physician: [text input]

Referring Physician: [text input]

Previous Diagnosis and Family History

Previous diagnosis of sleep apnea: [checkbox] What year was sleep study: [number input]

Any one in family with sleep apnea: [text input]

Current Medical Conditions

Current Medical Conditions:

[checkbox] Heart Disease
[checkbox] Stroke
[checkbox] Kidney Disease
[checkbox] High Blood Pressure
[checkbox] Heart Burn
[checkbox] Thyroid problems
[checkbox] COPD/Asthma
[checkbox] Edema
[checkbox] Overeating
[checkbox] Depression/anxiety
[checkbox] Atrial Fibrillation

Tonsils: [radio button: present] [radio button: removed] (what year): [number input]

Current Medications (or attach list): [textarea]

Are you currently on oxygen at home? [text input] How much? [text input]

My occupation is/was: [text input]

Allergies and Substance Use

Allergies to Medications (please list): [text input]

Caffeinated beverages: [text input] How many (include coffee, pop and energy drinks): [number input] What time is the last one for the day? [time input]

Alcohol: Do you drink alcohol? [radio button: never] [radio button: sometimes] [radio button: often] [radio button: rarely drink alcohol] How many alcoholic beverages do you consume per week? [number input]

Tobacco: Are you a tobacco user? (circle one) [radio button: Yes] [radio button: No] How much tobacco you use a day. PPD: [number input] If quit when: [text input] Vaping: [text input] THC: [text input]

Questionnaire Completion

Who completed this questionnaire? [text input]

If not the patient, how often do you directly observe the patient's sleep? [radio button: Frequently] [radio button: Occasionally] [radio button: Never]

Sleep Symptoms Checklist

Place a check beside any of the following statements that are true:

[checkbox] I have trouble going to sleep at night.
[checkbox] I have difficulty staying asleep and wake up frequently.
[checkbox] When I wake up during the night, I have trouble going back to sleep.
[checkbox] I wake up in the morning long before I have to.
[checkbox] I frequently can't sleep in the bedroom but can get up and sleep in another room on a couch, recliner, etc.
[checkbox] I have a job that involves night work.
[checkbox] I have a job that involves revolving shift work.
[checkbox] I have difficulty falling sleep because my legs are jumpy. (charley horses, creepy crawly feelings)
[checkbox] I sometimes wake up with feelings of aching or "pins and needles" in my legs.
[checkbox] I have been told that I snore.
[checkbox] I've been told that I stop breathing when I sleep.
[checkbox] I sometimes awaken with a choking sensation.
[checkbox] I have been told that I am restless at night.
[checkbox] I am unable to sleep in a flat position because of shortness of breath.
[checkbox] Dry mouth in morning.
[checkbox] Excessive sweating at night.
[checkbox] I usually have a bitter or sour taste in my mouth when I awaken at night or in the morning.
[checkbox] I sometimes wake up with heartburn.
[checkbox] I grind my teeth when I sleep.
[checkbox] I urinate frequently at night.
[checkbox] Attention/concentration problems.
[checkbox] Do you have headaches in the morning?
[checkbox] I have been told that I have convulsions, fits, or seizures at night.
[checkbox] I have bitten my tongue while asleep.
[checkbox] As an adult, I have wet my bed.
[checkbox] As an adult, I have been seen sleepwalking.
[checkbox] As an adult, I have been sleep talking.
[checkbox] I sometimes fall asleep unintentionally. I am frequently so sleepy when working that my work is poor.
[checkbox] I have had accidents when driving because I felt so sleep.
[checkbox] I have sometimes fallen asleep at very inappropriate times, such as driving, eating or during a conversation.
[checkbox] I've had the sensation of a sudden weakness in my legs, arms, face or whole body occurring on both sides equally, while awake, usually occurring in emotional situations, such as when laughing, crying, when angry, startled, etc.
[checkbox] I have hallucinations or dream like images when I am not actually asleep but while falling asleep or waking up.
[checkbox] I sometimes have felt paralyzed or unable to move when waking up or falling asleep.
[checkbox] My dreams are often very vivid.
[checkbox] While asleep, I have hit or been violent towards a bed partner or have injured myself unknowingly.

Sleep Habits

(Note: “night” refers to the time of day of your main sleep period)

On weekdays (workdays) I usually go to bed at: [time input] (AM or PM)

On weekdays I wake up at: [time input] (AM or PM)

On weekends (days off) I go to bed at: [time input] (AM or PM)

On weekends, I wake up at: [time input] (AM or PM)

The amount of time that I usually take to fall asleep is: [text input]

The number of times that I usually wake up during the night is: [number input]

If I wake up during the night, the amount of time it usually takes me to fall asleep again is: [text input]

How many days a week do you take naps? [number input] How long do these naps usually last? [text input]

Epworth Sleepiness Scale (ESS)

The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations. Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3, with 0 meaning you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation.

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think about how they would have affected you.

Use this scale to choose the most appropriate number for each situation: 0 = would never doze, 1 = slight chance of dozing, 2 = moderate chance of dozing, 3 = high chance of dozing. It is important that you circle a number (0 to 3) on each of the questions.

Situation	Chance of dozing (0 to 3)
Sitting and reading	[0] [1] [2] [3]
Watching television	[0] [1] [2] [3]
Sitting inactive in a public place--for example, a theater or meeting	[0] [1] [2] [3]
As a passenger in a car for an hour without a break	[0] [1] [2] [3]
Lying down to rest in the afternoon when circumstances permit	[0] [1] [2] [3]
Sitting and talking to someone	[0] [1] [2] [3]
Sitting quietly after lunch (when you've had no alcohol)	[0] [1] [2] [3]
In a car while stopped in traffic	[0] [1] [2] [3]

Safety and Sleepiness: I understand that I am being evaluated for a sleep disorder that is frequently associated with sleepiness during the daytime. The risks of driving and or operating heavy machinery have been explained to me. I have had the opportunity to ask questions of the sleep physician regarding driving and sleepiness.

Date Completed: [date input]

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