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Sleep Disorders Center
607-274-4617


Sleep Lab
New Patient Questionnaire


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**ATTENTION** You will need to complete this ENTIRE QUESTIONNAIRE before submitting it. If you navigate away from this page it DOES NOT SAVE your progress***

First Name
  
Middle Name
  
Last Name

Address
  
Apt # or Suite

City
State
  Zip
  

CONTACT INFORMATION
Home Phone*

(xxx-xxx-xxxx)
Cell Phone

(xxx-xxx-xxxx)
 
Email Address
 
Preferred Method of Contact:    Home Phone    Cell Phone    Email

Patient Date of Birth
Age


Height

Weight

Neck Size


Marital Status

 

Referring Physician:

 
Primary Care Physician:


Have you seen any other physician for your sleep problem? No    Yes
(please provide information)

SLEEP ISSUE QUESTIONS:
1. How do you describe your sleep problem? Check all that apply
Snoring    Difficulty falling asleep    Daytime Sleepiness
Difficulty awakening    Wake up during the night
2. How many nights a week do you have a sleeping problem?
3. How long have you had this problem?
4. Please estimate the severity of your problem(s)
mild    moderate   severe
5. Please describe your sleep problem, including when and how it began:

Please indicate the likelihood that you would fall asleep in the following situations. This refers to your usual way of life in recent times. Use the following scale to circle the most appropriate number for each situation:
0 = Would never dose
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

Situation 0 1 2 3
Sitting and reading
Watching TV
Sitting, inactive in a public place
(e.g., a theatre or a 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 lunch without alcohol
In a car, while stopped for a few minutes in traffic



SLEEP HABITS
6. On average, how long do you sleep at night?
7. How long does it take you to fall asleep?
8. How many times do you wake up at night?
(please describe):
9. Is the bedrooom quiet and dark? yes    no

10. Is your sleep often disturbed by your bed partner? yes    no

11. Do you sleep with pets? yes    no

12. Do your children sleep in your bed? yes    no

13. Do you worry excessively while in bed? yes    no

14. Do you drink caffeine within two hours of bedtime? yes    no

15. Do you do physical activity before bed? yes    no

16. Do you read before falling asleep? yes    no

17. Do you watch TV in bed before falling asleep? yes    no

18. Do you sleep better in your easy chair than in your bed? yes    no

19. Do you work variable or rotating shifts? yes    no

20. Do you feel excessively sleepy while driving? yes    no

21. Have you ever fallen asleep while driving or when stopped? yes    no

22. Do you fall asleep easily while riding as a passenger? yes    no

23. Have you fallen asleep in a public place? yes    no

24. Do you nap during the day? If so, how many and how long?
yes    no

25. Do you feel refreshed after a short nap? yes    no

26. Have you been told you talk in your sleep? yes    no

27. Have you been told you walk in your sleep? yes    no

28. Have you been told of any abnormal behaviors during sleep? (describe)
yes    no

29. Have you ever awakened with your whole body paralyzed? (explain)
yes    no

30. Do you hear or see things in the beginning or end of your sleep that are not real? yes    no

31. Have you ever had an episode of severe muscle weakness associated with laughter, anger or increased activity? (describe)

yes    no

32. Have you ever had sudden attacks of sleeping? (describe)
yes    no

33. Do you have restless or uncomfortable feelings in your legs? yes    no

  • Are these worse at night?
  • yes    no

  • Are they relieved with movement?
  • yes    no

  • Cramping in your legs at night?
  • yes    no

    34. Do you have headaches in the morning? yes    no

    35. Do you have jaw pain in the morning? yes    no

    36. Do you grind your teeth at night? yes    no

    37. Have you awakened short of breath or gasping for air? yes    no

    38. Have you awakened at night with heartburn, belching or cough? yes    no

    39. Have you had increased irritability or trouble thinking? yes    no

    40. Has daytime sleepiness affected your job or school performance? yes    no




    SNORING AND SLEEP APNEA

    Do you snore? yes    no
  • How often do you snore?
  • How severe is your snoring?
  • Has your snoring become progressively worse?
  • Have you ever awakened because of your snoring?
  • Have you been observed to stop breathing when you sleep?
    In what positions do you snore? (please check all that apply) back    side
    stomach    sitting
    Which best describes your pattern of snoring? snoring is present continuously
    snoring is present occasionally
    I snore, stop breathing then snore again

    REVIEW OF SYSTEMS

    Cardiac
    1. Do you have chest pain or pressure? yes    no
    2. Do you have palpitations or a racing heart? yes    no
    3. Do you have ankle or feet swelling? yes    no
    4. Do you have high blood pressure? yes    no
    Other
    Pulmonary
    1. Shortness of breath? yes    no
    2. Chronic cough? yes    no
    3. Asthma? yes    no
    4. COPD? yes    no
    Other
    Gastrointestinal
    1. Do you have heartburn? yes    no
    2. Difficulty with your bowels? yes    no
    Explain
    ENT
    1. Headaches? yes    no
    2. Nasal stuffiness or discharge? yes    no
    3. Sinus issues? yes    no
    4. Sore Throat? yes    no
    5. Ear Pain? yes    no
    6. Do you have dentures? yes    no
    7. Have you had your tonsils removed? yes    no
    Other
    Genitourinary
    1. Difficulty passing urine? yes    no
    2. Do you wake up to urinate?
    Times per night?
    yes    no
    3. Are currently going through menopause? yes    no
    4. Have difficulty with erections? yes    no
    Musculoskeletal
    1. Do you have chronic pain? yes    no
    2. Does your pain interfere with sleep? yes    no
    3. Do you awake with numbness in your limbs? yes    no
    Other
    Neurological
    1. Do you have numbness or tingling? yes    no
    2. Dizziness or balance issues? yes    no
    3. Blurry vision or recent black outs? yes    no
    4. Do you awaken from sleep feeling paralyzed? yes    no
    5. History of stroke? yes    no
    6. History of Migraines? yes    no
    Psychosocial
    1. Do you feel Depressed or anxious? yes    no
    2. Are you more irritable than in the past? yes    no
    3. Do you smoke? yes    no
    4. Do you drink alcohol? yes    no
    5. Do you use recreational drugs? yes    no
    6. Do you smoke marijuana? yes    no
    Other Health Concerns:

    Please complete the following medication list:
    (Please include all over the counter medications and supplements)
    MEDICATION NAME DOSAGE FREQUENCY REASON TAKEN
    Additional Medications:


    Please complete the following allergy list, including reaction:
    ALLERGY REACTION
    Additional Allergies:


    SURGICAL PROCEDURES:
    Type of Surgery Date Place

    ADDITIONAL COMMENTS:

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