Sleep Assessment
Questionnaire used to identify sleep disorder candidates
For Patient:
First Name:
Last Name:
Date of birth:
Height:
Weight:
Age:
Please list any medical problems within the last 5 years (hypertension, diabetes, surgery, etc.)
Have you suffered a heart attack or stroke?
When?
Select the appropriate response for each:
1. Do you snore at night?
Yes
No
2. Witnessed pauses in breathing while asleep?
Yes
No
3. Do you have difficulty falling asleep?
Yes
No
4. Do you have difficulty maintaining sleep?
Yes
No
5. Experience a restless sensation in legs while lying awake in bed?
Yes
No
6. Kicking and twitching movements while asleep?
Yes
No
7. Experience excessive daytime tiredness?
Yes
No
8. Have you ever awakened feeling paralyzed?
Yes
No
9. Experienced a sudden loss of strength in your arms or legs?
Yes
No
10. If the previous answer is Yes, were these events brought on by a sudden, frightening event or laughter?
Yes
No
Check all that apply:
Do you frequently awaken with:
dry mouth
nasal congestion
Headache
chest pain
Choking & gasping
feeling groggy & un-refreshed