Dr P J H Venn MB FRCA / Sleep Disorder Centre
Dr J C Ratoff FRCP / Holtye Road
East Grinstead RH19 3DZ
When completed, please email this form to Please be advised this is not considered a secure method of communication/transfer and is used at your own risk.
GENERAL MEDICAL QUESTIONNAIRE
INSOMNIA
A.Patient Details
Name: Click here to enter text. DOB: Click here to enter text.
Address line 1: Click here to enter text.
Address line 2: Click here to enter text.
Address line 3: Click here to enter text.
Address line 4: Click here to enter text. Postcode: Click here to enter text.
Daytime Tel No:Click here to enter text.Evening Tel No: Click here to enter text.
We are now sending text reminders of appointments – if you do
not wishto receive such texts, please tick the box
Mobile Tel No: Click here to enter text.E-mail address: Click here to enter text.
In case of emergency contact: Name: Click here to enter text. Tel: Click here to enter text.
GP and Address: Click here to enter text.
GP Tel No:Click here to enter text.Your Occupation: Click here to enter text.
B. Do you have or have you suffered from any of the following:
Please answer ALL of the following questions by ticking the appropriate box & circling the appropriate condition
Yes / No- Heart disease/Rheumatic Fever
- Palpitations/chest pain at rest (☐) on exertion (☐)
- High blood pressure
- Undue shortness of breath on exertion at rest (☐) lying flat (☐)
- Respiratory Disease - Bronchitis/Asthma /COPD
- Arthritis or muscle disease/neck or back problems
- Diabetes- Type 1/Type 2
- Epilepsy/stroke/blackouts
- Hepatitis/Jaundice
- Urinary or kidney problems
- Anxiety Disorders
- Thyroid problems - Hypothyroidism/Hyperthyroidism
C. Please list any previous operations, serious illnesses or chronic medical conditions
Operation, illness, conditionDate
Click here to enter text.Click here to enter a date.
Click here to enter text.Click here to enter a date.
E. Medication:
Yes / NoAre you currently taking any drugs, medicines or tablets? / ☐ / ☐ /
Including the contraceptive pill, sleeping pills, painkillers, aspirin and inhalers.
If ‘Yes’, please list
Click here to enter text.
Please bring repeat prescription with you if applicable.
F. Have you ever had any allergic reactions to or known allergies to:
Yes / No- Drugs/Medications (eg Penicillin)
- Other substances? (eg Plasters/Rubber/Latex)
Please list: Click here to enter text.
G. Do you smoke? / Yes / NoHow long have you smoked? Click here to enter text. / ☐ / ☐ /
What and how many per day? Click here to enter text.
H. Do you drink alcohol? / Yes / NoHow many units per week? Click here to enter text.
1 unit = small glass of wine or half pint of beer or cider or 1 small measure of spirit / ☐ / ☐ /
Weight now? / Click here to enter text. / Are you married?
or / Yes?
☐ / Please
tick / No?
☐
Weight when married? / Click here to enter text. / Do you have a partner?
or / Yes?
☐ / Please
tick / No?
☐
Height? / Click here to enter text. / Are you single? / Yes?
☐ / Please
tick / No?
☐
Collar size (if known) / Click here to enter text. / How long have you
been together? / Click here to enter text. /
IF YOU NEED TO COME IN FOR AN INPATIENT STAY THE FOLLOWING QUESTIONS WILL HELP US ENSURE THAT WE PROVIDE EVERYTHING YOU NEED
Weight: / Click here to enter text. / Height: / Click here to enter text. / Collar Size if known: / Click here to enter text. /- Are you a wheelchair user?
- Do you have any equipment which you need to bring with you to
aid you?
If Yes, please give details:Click here to enter text.
- Do you have a carer who needs to accompany you and stay
overnight?
- Do you have a history of blackouts, falls or fits?
- Do you require oxygen overnight?
How many times, on average, do you get up in the night to use the toilet? Click here to enter text.
- Have you had recent episodes of sleepwalking?
If yes, how frequently does this occur? Click here to enter text.
- Do you have any of the following?Speech difficulties
Hearing difficulties / Yes / ☐ / No / ☐ /
Language difficulties / Yes / ☐ / No / ☐ /
Visual difficulties / Yes / ☐ / No / ☐ /
Learning or comprehension difficulties / Yes / ☐ / No / ☐ /
If you answered yes to any of the above, please give details:
Click here to enter text.
- Have you ever been diagnosed with MRSA?
If yes, whenClick here to enter text.
Have you now been tested clear? / Yes / ☐ / No / ☐ /- Do you have any infectious diseases which could be
transferred to others?
If yes, please give details: Click here to enter text.
- If a member of staff were to wake you in the night how would you react?
Click here to enter text.
- Do you have any other specific needs (eg religious, personal)
that we should consider during your stay?
If yes, please give details: Click here to enter text.
Insomnia Severity Index
The Insomnia Severity Index has 7 questions. The 7 answers are added up to get a total score. When you have your total score, look at the “Guidelines for Scoring/Interpretation” below to see where your sleep difficulty fits.
For each question, please CIRCLE the number that best describes your answer.
Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s).
Insomnia Problem / None / Mild / Moderate / Severe / Very Severe1. Difficulty falling asleep / 0☐ / 1☐ / 2☐ / 3☐ / 4☐
2. Difficulty staying asleep / 0☐ / 1☐ / 2☐ / 3☐ / 4☐
3. Problems waking up too early / 0☐ / 1☐ / 2☐ / 3☐ / 4☐
4. How SATISFIED/DISSATISFIELD are you with your CURRENTsleep pattern?
Very Satisfied
0☐ / Satisfied
1☐ / Moderately Satisfied
2☐ / Dissatisfied
3☐ / Very Dissatisfied
4☐
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
Note at all noticeable
0☐ / A Little
1☐ / Somewhat
2☐ / Much
3☐ / Very much noticeable
4☐
6. How WORRIED/DISTRESSED are you about your current sleep problem?
Not at all worried
0☐ / A little
1☐ / Somewhat
2☐ / Much
3☐ / Very much worried
4☐
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?
Not at all interfering
0☐ / A little
1☐ / Somewhat
2☐ / Much
3☐ / Very much interfering
4☐
Guidelines for Scoring/Interpretation:
Add the scores for all seven items (questions 1 + 2 + 3 + 4 + 5 + 6 + 7 = Click here to enter text.your total score
Total score categories:
0 - 7 = No clinically significant insomnia
8 - 14 = Sub-threshold insomnia
15 - 21 = Clinical insomnia (moderate severity)
22 - 28 = Clinical insomnia (severe)
Used via courtesy of with permission with Charles M. Morin, Ph.D., Université Laval
THE EPWORTH SLEEPINESS SCALE
Name:Click here to enter text.
Your age (Yrs): Click here to enter text.Sex: Male ☐ Female ☐ Date:Click here to enter text.
How likely are you to doze off or fall asleep in the situations described in the box below, in contrast to feeling just tired?
Even if you haven't done some of these things recently, try to work out how they would have affected you.
Using the following scale to choose the most appropriate number for each situation, please fill in the left hand column and ask your partner to fill in the right hand column:-
0 = would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Chance of dozingSituation / Patient / Partner’s Assessment of Patient
Sitting and reading / Choose an item. / Choose an item. /
Watching TV / Choose an item. / Choose an item. /
Sitting, inactive in a public place (eg a theatre or a meeting) / Choose an item. / Choose an item. /
As a passenger in a car for an hour without a break / Choose an item. / Choose an item. /
Lying down to rest in the afternoon when circumstances permit / Choose an item. / Choose an item. /
Sitting and talking to someone / Choose an item. / Choose an item. /
Sitting quietly after a lunch without alcohol / Choose an item. / Choose an item. /
In a car, while stopped for a few minutes in the traffic / Choose an item. / Choose an item. /
Thank you for your co-operation
GAD-7
Over the last 2 weeks, how often have youbeen bothered by the following problems?
(Use “✔” to indicate your answer” / Not at
all / Several days / More than half the days / Nearly every day
- Feeling nervous, anxious or on edge
- Not being able to stop or control worrying
- Worrying too much about different things
- Trouble relaxing
- Being so restless that it is hard to sit still
- Becoming easily annoyed or irritable
- Feeling afraid as if something awful might happen
Column Totals:______+ ______+ ______+ ______
= Total Score ______
PHQ-9
Over the last 2 weeks, how often have youbeen bothered by the following problems?
(Use “✔” to indicate your answer” / Not at
all / Several days / More than half the days / Nearly every day
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
- Trouble falling or staying asleep or sleeping too much
- Feeling tired or having little energy
- Poor appetite or overeating
- Feeling bad about yourself or that you are a failure or have let yourself or your family down
- Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
- Thoughts that you would be better off dead or of hurting yourself in some way
Column Totals:______+ ______+ ______+ ______
= Total Score ______
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficultat all
☐ / Somewhat
difficult
☐ / Very
difficult
☐ / Extremely
difficult
☐
CLINICAL
OUTCOMESin ROUTINE EVALUATION
OUTCOME MEASURE / Site ID / Age / Male
Female
Letters only numbers only
Client ID
Therapist ID numbers only(1) numbers only (2)
Sub codes
D D M M Y Y Y Y
Date form given
IMPORTANT-PLEASEREADTHIS FIRST
Thisformhas34statementsabouthowyouhavebeenOVERTHELASTWEEK. Pleasereadeachstatementandthinkhowoftenyoufeltthatwaylastweek. Thenticktheboxwhichisclosesttothis.
Please useadarkpen(notpencil)andtickclearlywithinthe boxes.
Over the last week / Not at
all / Only Occasionally / Sometimes / Often / Most or all the time / Office Use Only
- I have felt terribly alone and isolated
- I have felt tense, anxious or nervous
- I have felt I have someone to turn to for support when needed
- I have felt OK about myself
- I have felt totally lacking in energy & enthusiasm
- I have been physically violent to others
- I have felt able to cope when things go wrong
- I have been troubled by aches, pains or other physical problems
- I have thought of hurting myself
- Talking to people has felt too much for me
- Tension & anxiety have prevented me doing important things
- I have been happy with the things I have done
- I have been disturbed by unwanted thoughts & feelings
- I have felt like crying
- I have felt panic or terror
- I made plans to end my life
- I have felt overwhelmed by my problems
- I have had difficulty getting to sleep or staying asleep
- I have felt warmth or affection for someone
- My problems have been impossible to put to one side
- I have been able to do most things I needed to
- I have threatened or intimidated another person
- I have felt despairing or hopeless
- I have thought it would be better if I were dead
- I have felt criticised by other people
- I have thought I have no friends
- I have felt criticised by other people
- Unwanted images or memories have been distressing me
- I have been irritable when with other people
- I have thought I am to blame for my problems and difficulties
- I have felt optimistic about my future
- I have achieved things I wanted to
- I have felt humiliated or shamed by other people
- I have hurt myself physically or taken dangerous risks with my health
(Total score for each dimension
Divided by number of items (W) (P) (F) (R) All Items All minus R
completed in that dimension)