Atlantic Sleep Health Diagnostic Associates, LLC

an Affiliate of Atlantic Pulmonary & Critical Care Associates, PA

110 E Jimmie Leeds Road

Galloway, NJ 08205-9508

609-748-7900

PATIENT’S SLEEP QUESTIONNAIRE

Your answers to the following questions will help us to obtain a better understanding of your sleep problems. Please answer every question to the best of your ability.

Name: ______Date of Birth:______Age:______Sex:_____ Marital Status:_____
Address:______City:______State/Zip:______
Home Phone #:______Cell Phone #:______Work Phone #:______
Occupation: ______How did you hear about us? ______
Your Referring Physician: ______Weight: ______Height: ______
Has your weight Changed? Yes / No Amount: ______Time Involved: ______

Weight Gain: ______or Weight Loss: ______

Describe your sleep or sleep problems (briefly): ______

______
______
______

When did your sleep problems begin? ______

During Week Weekend

What time do you go to bed? ______

What time do you get up? ______

What time do you go to work? ______

What time do you leave work? ______

How many times do you fall asleep during the day? ______

How many times do you fall asleep during the evening? ______

When you awaken from a nap, do you feel

refreshed? Yes / No

What is the time interval between naps? ______

DATE OF OFFICE EVALUATION: ______

1. Do you have trouble going to sleep? Yes or No

  1. Do you frequently awaken during the night? Yes or No
  1. Do you wake up and not go back to sleep? Yes or No
  1. Do you feel extremely drowsy during the day? Yes or No

What time of day, in particular ______a.m. ______p.m.

  1. Do you snore? Yes or No
  1. Do you toss, turn or kick? Yes or No
  1. Does your snoring or kicking prevent someone from sleeping in the same bed with you? Yes or No
  1. Does your snoring waken people in adjoining rooms? Yes or No
  1. Do you wake up suffocating? Yes or No
  1. Do you waken with a Headache, feeling tired, disoriented? Yes or No
  1. How many times do you go to the bathroom during the night?______
  1. Have you been told that you stop breathing for any period of time during the night? Yes or No
  1. Do you fall asleep at inappropriate times, such as a business meeting, during conversations, etc.? Yes or No
  1. Have you ever fallen asleep while driving a motor vehicle? Yes or No
  1. Have you had any motor vehicle accidents? Yes or No
  1. Have you had accidents at work related to sleepiness? Yes or No
  1. Do you grind your teeth during sleep? Yes or No
  1. Do you have a restless or creeping feeling in your legs that is decreased by moving your legs

or walking? Yes or No

  1. Do you hallucinate before sleeping? Yes or No
  1. Do you ever feel that you cannot move after lying down or just after you awaken? Yes or No
  1. Do you ever feel sudden weakness in you limbs when laughing or emotional? Yes or No
  1. Do you ever find yourself somewhere and not know how you got there? Yes or No
  1. For an average day, estimate your intake of…… Coffee______Cups

Tea______Cups

Alcohol______Cups

Cigarettes______Packs per day x ______years

Patient Name: ______Date of Birth: ______

  1. Do you drink alcohol in the 3 hour period before bedtime? Yes or No
  1. Do you take any medications, including any sleeping pills, tranquilizers or over

the counter medication? Yes or No

If yes please list medications: ______

______

______

______

______

  1. Have you ever had a head injury of CNS infections? Yes or No
  1. Have you ever had a nasal injury? Yes or No
  1. Do you have blocked sinuses? Yes or No
  1. Do you have nasal allergies? Yes or No
  1. Have you had a tonsillectomy or adenoidectomy? Yes or No
  1. Have you had nasal surgery? Yes or No
  1. Have you had a history of sleep problems? Yes or No
  1. Have you been divorced? Yes or No
  1. (For Women), Is your menstrual cycle regular? Yes or No
  1. Do you have any Diet Restrictions or Special Dietary Requirements? Yes or No

If yes, Please Describe: ______

______

  1. Do you have any physical limitations or do you use any handicapped assistive devises? Yes or No

If yes, Please Describe: ______

______

37 Do you have any allergies, including medication allergies? Yes or No

Please list allergies: ______

______.

38. Have you ever had surgery? Yes or No

Please list reason and approximate date: ______

______

39. Have you ever been hospitalized (other than for surgery)? Yes or No

Please list reason and approximate date: ______

______

Patient Name:______Date of Birth:______

Patient Signature:______Date:______

Revised 03/05/14