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30230 Rancho Viejo Road, Suite 200
San Juan Capistrano, CA 92675
Phone: (949) 443-4303 and (949) 443-4114
Fax: (949) 443-4033 and (949) 443-4150
CONFIDENTIAL SLEEP QUESTIONNAIRE
Patient’s Name: _________________________________________________ DoB: ______/ ______/ _______
Age: __________ Gender: Male Female Height: ______ inch Weight: ______ lbs Neck Size: ______
Please describe your sleep problem for which you are here today:_________________________________________
________________________________________________________________________________________________
How long have you this problem?
Less than 1 month 1-3 months 3-6 months more than 6 months 1 year or more
How often do you experience this problem?
1-2 times per week 3-5 times per week every night
How would you rate the current condition of this problem?
Staying the same Getting better getting worse
Have you and your bed partner had to sleep separately due to this problem?
Yes No If yes, for how long _____________________________
Have you had prior sleep studies or evaluation for this problem? Yes No
Have you received any prior treatment for this problem? Yes No
If yes, please mentioned the date, place/facility the study/evaluation was done: -
________________________________________________________________________________________________
What treatment you have received? __________________________________________________________________
SLEEP SCHEDULE AND HYGIENE
What is your occupation? __________________ Do you work shift work? Yes, please explain ____________ No
Do you have trouble sleeping when you are doing shift work? Yes No
What is your bedtime? ___________________ p.m. / a.m. Is your bedtime: Same everyday
Depends on (please describe): ___________________________________________________________
Varies (please describe): ________________________________________________________________
How many hours do you usually sleep on weekdays or days that you work? ________________
How many hours do you usually sleep on weekends or day that you do not work? ________________
How long does it take you to go to sleep? Mins/hours ________________
SLEEP DISORDERS CENTER
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How many times do you awaken during the night? ________________
How many times do you get up to use the bathroom at night? ________________
What time do you get up on workdays and weekends? _______ a.m./p.m. ________ a.m./p.m.
Comfortable sleeping position is:
On side on back on stomach in bed with head elevated in a chair or recliner
How do you feel when you wake up from regular sleep time?
Well rested/refreshed somewhat rested same as bedtime tired
Do you nap or doze during the day? Yes No How long is your nap in the AM? _____ mins/hours
Are any of these naps intentional? Yes No How long is your nap in the PM? _____ mins/hours
If you nap or doze during the day, how do you feel when you wake up?
well rested/refreshed somewhat rested same as bedtime Tired
Do you read in bed? Yes No Do you watch TV in bed? Yes No
Do you write in bed? Yes No Do you eat in bed? Yes No
Do you worry in bed? Yes No Do you have arguments in bed? Yes No
INSOMNIA
Do you often have trouble getting to sleep at night? Yes No
What is the average number of minutes it take you to fall asleep at night? __________ mins
Do you often have awakening during the night? Yes No
If yes, what is the average number of times per night that you wake up? _____________
If yes, why do you wake up? ____________________________________________________________________
Do you have long periods when you awaken and are not able to get back to sleep? Yes No
If yes, how long are these periods of wakefulness when added together? ____________ minutes per week
Are you bothered by waking up too early and not being able to get back to sleep? Yes No
If yes, what is the average number of nights per week? ___________________
Do you use any drugs or medications to aid with sleep? Yes No
List medications: ________________________________________________________________________________
How many times per week do you used these? _______________________________
MOVEMENT
Are your bed covers “messyin the morning when you wake up? Yes No
Do you awaken yourself by kicking your legs during the night? Yes No
Has your bed partner ever complained of your legs kicking during the night? Yes No
Do you have a restless sense of discomfort in your legs during the waking hours? Yes No
Do you exercise regularly? Yes No
PARASOMNIAS
Did you have a sleep problem as a child? Yes No If yes, explain: _______________________
Do you currently have nightmares or night terrors? Yes No
If yes, how frequently? ________ ( per week/ month/year) If yes, at what age did they begin? __________
Do you grind or clench your teeth at night? Yes No
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Did you wet the bed as a child? Yes No If yes, for how many year? ______
Have you ever wet the bed as an adult? Yes No
Have you ever been told that you walk in your sleep? Yes No
Have you even told that you make unusual movements other than leg kicking during sleep? Yes No
EXCESSIVE SLEEPINESS
Do you feel excessively sleepy in the daytime? Yes No
If yes, how long has this occurred for? ______________ months/years
Have you ever had an accident or near miss accident because of falling asleep while driving? Yes No
If yes, please explain: __________________________________________
How often do you snore?
Never Rarely Occasionally Frequently Always
If you do, for how many : _______________ years and or months
How often does sleep position affects your snoring?
Never rarely Occasionally Frequently Always
In which position do you snore most loudly?
back right side left side stomach other
How often have you been told that you stop breathing during sleep?
Never rarely Occasionally Frequently Always
How often do you wake up with morning headaches?
Never rarely Occasionally Frequently Always
How often do you awaken with a dry mouth or sore throat?
Never rarely Occasionally Frequently Always
How often are you confused in the morning?
Never rarely Occasionally Frequently Always
How often do you have night sweats?
Never rarely Occasionally Frequently Always
Please recall you weight history if applicable:
Weight at 20 _______ lbs. Weight at 30 _______ lbs. Weight at 40 _______ lbs.
Weight at 50 _______ lbs. Weight at 60 _______ lbs. Heaviest Weight _______ lbs. at ________ years of age
If you have gained weight, do you feel that you sleepiness is associated with it? Yes No
Have you ever had any exceptionally vivid dreams just as you were falling asleep or waking up? Yes No
If yes, please describe: __________________________________________________________
How often? Yearly Monthly weekly nightly
Have you ever felt paralyzed for a few seconds as you awaken? Yes No If yes, how often? ____________
If yes, how often? Yearly monthly
Have you experienced episodes of muscle weakness, loss of muscle strength, or limp muscles in any part of your body during
the following situations?
When you laugh? Yes No When you are angry? Yes No
When hearing or telling a joke? Yes No
Just as you are dozing off or immediately upon awakening, do you ever hallucinate? Yes No
Signature: ______________________________________ Date: ____________________________
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