Patient History Questionnaire
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Date:
What is the main reason you have been referred to the Sleep Disorder Center?
Feeling just tired ? this refers to your usual way of life in recent time Even if you have not done some of these things recently, try to work out how they would have affected you . Using the following scale, circle the most appropriate number for each situation.
Sitting and Reading:
Watching TV:
Sitting inactive in a public place (in awaiting area or in a meeting):
As 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:
In a car, while stopped for a few minutes in the traffic:
Do you know if you
Do your legs ever get restless – do you feel like you need to get up and walk around?
Every night:
Never:
Do your legs ever feel hot, burny, itchy, or like the skin is crawling when you are trying to sleep?
Every night:
Never:
Do you dream while falling asleep?
Every night:
Never:
Do you ever wake up and feel paralyzed?
Every night:
Never:
Do you ever feel weak or unusual when you are angry or excited or laughing?
Every night:
Never:
Do you nap (accidentally or on purpose)?
Every night:
Never:
Do you dream when you nap?
Every night:
Never:
How do you feel after a nap?:
Do you ever wake up with - only those which apply to you?
Do you feel the activity when you wake up from sleep?:
DO you ankles ever swell up?
Every Day:
Never:
Do you have (only those which apply to you)?
Do you smoke?
Do you drink alcohol?
Every night:
Never:
Has your nose ever been broken?:
Do you have your tonsils?:
Can you breathe through your nose nostrils?:
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