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?  YesNo
     2. Witnessed pauses in breathing while asleep?  YesNo
     3. Do you have difficulty falling asleep?  YesNo
     4. Do you have difficulty maintaining sleep?  YesNo
     5. Experience a restless sensation in legs while lying awake in bed?  YesNo
     6. Kicking and twitching movements while asleep?  YesNo
     7. Experience excessive daytime tiredness?  YesNo
     8. Have you ever awakened feeling paralyzed?  YesNo
     9. Experienced a sudden loss of strength in your arms or legs?  YesNo
     10. If the previous answer is Yes, were these events brought on by a sudden, frightening event or laughter?  YesNo

Check all that apply:

Do you frequently awaken with: dry mouth    nasal congestion
                                                Headache    chest pain
                                                Choking & gasping    feeling groggy & un-refreshed