Sleep Consult Questionnaire Form

Patient Name *

First

Last

Date of Birth (00/00/0000) *

Sex *

Height *

Weight *

Address *

City *

State *

Zip Code *

Patient's phone number *

Email

Preferred method of contact *

Referring Physician (Name and Address)

Other physicians who should receive this report

Marital status *

Occupation *

Why are you having a sleep study?

What is your present CPAP setting?

What mask do you use?

If you have a MAD, which one do you have?

When do you work or are generally awake?

Day
Night
Rotating shifts

When do you go to bed?

How long does it take you to fall asleep?

Do you have trouble falling asleep? (If yes, then please answer the next five questions.)

Yes
No

Do you need medication to help you sleep?

Yes
No

If you need medication, please give the names and dosages.

Why do you have trouble falling asleep?

Prior to bedtime do you?

Please tell any particular details of your bedtime routine that seems to keep you awake.

What time do you awaken in the morning?

When you awaken in the morning, do you have a headache?

Yes
No

When you awaken in the morning, do you feel tired and need more sleep?

Yes
No

Do you awaken frequently at night?

Yes
No

If so, how many times?

If the answer is yes, then why do you awaken?

Do you have trouble falling back to sleep?

Yes
No

When you can not sleep do you?

Watch TV
Work on the computer
Read
Eat

Do you snore?

Yes
No

If so, for how long?

Are you already on CPAP/BiPAP or a MAD?

Yes
No

Do you snore while wearing CPAP or MAD?

Yes
No

How loud is the snoring?

Soft
Loud
Very Loud
So loud no one wants to be in the room with you

Do you stop breathing during sleep?

Yes
No
Do not know

If you are not aware of it, has anybody seen you or heard you stop breathing during sleep?

Yes
No

Check all the symptoms that you experience during sleep.

Do you have these symptoms if you are wearing CPAP or the MAD?

Yes
No

Do you have leg movements and twitching during sleep?

Yes
No

If so, for how long?

Do you awaken with pain in the legs and/or arms?

Yes
No

Do you walk in your sleep?

Yes
No

Have you ever hurt yourself or others while walking in your sleep?

Yes
No

Do you have excessive daytime sleepiness?

Yes
No

What time of day is the worst?

How bad is the sleepiness?

Mild (able to function)
Moderate (very hard to stay awake)
Very bad (can not stay awake)

Have you fallen asleep while driving?

Yes
No

While talking to someone?

Yes
No

At a meeting?

Yes
No
Does not apply

Operating heavy machinery?

Yes
No
Does not apply

Have you had any accidents related to falling asleep?

Yes
No

How Many?

Do you have episodes of sudden onset of uncontrollable sleep during the day?

Yes
No

Do you have fleeting episodes of some weakness in the legs or arms?

Yes
No

Is this brought on by laughter or strong emotion?

Yes
No
Does not apply

How long have you had these symptoms?

Do you work night shifts?

Yes
No
Does not apply

Rotating shifts?

Yes
No
Does not apply

Do you have trouble concentrating?

Yes
No

Do you have trouble with memory?

Yes
No

Cardiac disease

Pulmonary

Neurologic

Psychiatric disease

Anxiety disorders
Claustrophobia
Schizophrenia
Hostile behavior

Gastrointestinal

Urinary

Endocrine

Diabetes mellitus
Hypothyroidism
Acromegaly

Do you take insulin?

Yes
No

If there is heart failure, how bad is it?

Shortness of breath at night?

Yes
No

Shortness of breath with only a small amount of exertion?

Yes
No

Are You pregnant?

Yes
No
Does not apply
Post menopausal

Please list any surgeries you have had.

Chest/Heart?

Ear, nose throat, facial reconstruction?

Orthopedic?

Other?

Do you smoke?

Yes
No

Did you ever smoke?

Yes
No

Cigars?

Yes
No

Cigarettes?

Yes
No

How much?

Do you drink any caffeinated drinks, such as coffee or tea or cola?

Yes
No

How much?

What times of day?

Do you drink alcohol?

Yes
No

When was the last time you consumed any alcohol? (Date)

Please list all medications that you are currently taking.

Please list any allergies you have.

Is there a family history of : Sleepiness?

Yes
No

Snoring?

Yes
No

Narcolepsy?

Yes
No

Excessive sleepiness?

Yes
No

What time did you awaken today?

How many hours of sleep did you have last night?

Was the sleep restful?

Yes
No

Did you take any naps earlier today prior to coming to the sleep lab?

Yes
No

Did you take any medications today?

Yes
No

If so, please list them and at what times.

When did you last eat?

When did you last have anything with caffeine?

Alcohol?

When did you last smoke (if you do smoke)?

Are you tired right now?

Yes
No

Please score your sleepiness using the Stanford Sleepiness Scale =

How long did it take you to fall asleep?

Is this similar to the usual time it takes you to fall asleep?

Yes
No

How many hours of sleep do you believe you had during this sleep study?

Was the sleep restful?

Yes
No

Was the sleep similar to your usual sleep at home?

Yes
No

How many times do you believe you awakened during sleep?

Were the awakenings due to sounds or noise or lights in the sleep lab?

Yes
No

Is this similar to the usual number of awakenings you have while sleeping?

Yes
No

Did you dream?

Yes
No

Do you feel awake and rested?

Yes
No

Please score your sleepiness using the Stanford Sleepiness Scale =

Could you have slept longer?

Yes
No

If you received a trial of CPAP or BiPAP, do you feel it improved the quality of sleep?

Yes
No

Do you have any physical complaints now?

Do you have any suggestions to make your sleep in the sleep lab more comfortable?

Check what best describes your level of alertness or sleepiness right now:

Feeling active, vital, alert, wide awake.
Functioning at a high level but not at peak, still able to concentrate.
Relaxed, awake, but not fully alert, responsive.
A little foggy, let down.
Foggy, beginning to lose track, difficulty in staying awake.
Sleep, prefer to lie down, woozy.
Almost in reverie, cannot stay awake, sleep onset appears imminent.

Chance of dozing while sitting and reading? 0 = would never doze 1 = slight chance of doing 2 = moderate chance of dozing 3 = high chance of dozing

Watching TV

Sitting, inactive in a public place (e.g., theater, meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

Total Score

Current ER Wait Time:
Minutes Learn More →

Let us help you…

About Evanston Regional Hospital

Site Information & Policies