Sleep Form

Primary Sleep Compliant - Please check all that apply *

Excessive tiredness

Snoring

History of narcolepsy

Trouble initiating sleep

History of sleep apnea

Abnormal sleep behavior

Trouble maintaining sleep

Restlessness of legs pre-sleep

History of Restless Leg Syndrome

Other

Has anyone OBSERVED you stop breathing during your sleep? *

Yes

No

Are you on supplemental Oxygen? *

Yes

No

Do you experience restlessness/sensations in you legs pre-sleep? *

Yes

No

How would you describe your dreams? *

Normal

Excessive

Diminished

Disturbing

Social Security Number

In a car, while stopped for a few minutes in traffic *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Address

Once asleep, how often do you awaken during the night *

Primary Care Doctor's Name/Facility *

Are you a current smoker? *

Yes

No

Emergency Contact Phone Number *

Email: *

Check here to receive email updates

Do you exercise on a regular basis? *

Yes

No

Referring Doctor's Name/Facility *

Why were you referred to us? *

What time do you regularly get out of bed? *

Phone *

NECK circumference is more than 16 inches around? *

Yes

No

Sitting inactive in a public place *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Cell Phone *

Surgical History: *

If Yes, Please upload your medication "or" bring it to your appointment

Allergies: *

Lying down to rest in the afternoon if circumstances permit *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? *

Yes

No

BMI more than 35? *

Yes

No

If former smoker, when did you quit?

Date of Birth *

Are you a previous smoker? *

Yes

No

AGE over 50 years old? *

Yes

No

Phone of your Pharmacy *

Do you take any medications? *

Yes

No

Do you have or are you being treated for high blood PRESSURE? *

Yes

No

Phone Number of Doctor *

How many hours of sleep do you get per night, on average? *

Do you gasp for air &/or choke during the night? *

Yes

No

Do you often feel TIRED, fatigued, or sleepy during daytime? *

Yes

No

Have you been told that your limbs jerk at night? *

Yes

No

Previous Hospitalizations: *

Sitting and talking to someone *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Have you been told you snore? *

Yes

No

Phone Number of Doctor *

Address of your Pharmacy *

Address *

Name of your Pharmacy *

Alcohol use: *

Emergency Contact *

Sitting quietly after lunch without alcohol *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Caffeine use: *

Have you ever been addicted to drugs/alcohol? *

Yes

No

As a passenger in a car for an hour without a break *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Watching TV *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

Sitting and Reading *

0=would never doze

1=slight chance of dozing

2=moderate chance of dozing

3=high chance of dozing

GENDER: Male? *

Yes

No

How long has problem existed? *

Ethnicity *

Hispanic/Latino

Not Hispanic/Latino

Unreported/Refused to Report

Bed Partners (including animals) *

Yes

No

Name: *