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Secure Form :: Sleep Study Interview
** Required Fields

The following Questions will help us understand your sleep problems. Please answer the question accurately.
All information will be kept confidential.

PATIENT INFORMATION

Last Name **
First Name
Middle Name
Date Of Birth
Gender
Height (inches)
Weight (lbs)
Email Id
Phone (Home)
Phone (Work)
Phone (Cell)
Address
City


State
Zip
Referring Physician : Name
Referring Physician : Phone
Referring Physician : Address

SLEEP STUDY INTERVIEW INFORMATION

* * *
  What problem are you seeking help from the sleep clinic ?   
Sleepiness Unable to get enough sleep Snoring Breathing Stops
Other
Please Explain
Occupation
What are your working hours
Do you Smoke ?
If Yes, How much per day ?
Do you drink Alcohol?
If Yes, How much per day ?
* * *
  Epworth Scale  
How likely are you to doze or fall asleep in the following situations, in contrast to feel tired ?
This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you.

Sitting and reading
 
Sitting and talking to someone
Sitting quietly after lunch without alcohol
 
Watching TV
Lying down to rest in the afternoon when circumstance permits
 
Sitting inactive in a public place (i.e. theatre or meeting)
As a passenger in a car for an hour without a break
 
In a car stopped for a few minutes stopped in traffic
* * *
  Problems over past 2 weeks  
Have you been bothered by any of the following problems over the past two weeks ?

Little interest or pleasure doing anything
 
Trouble concentrating on things such as reading the newspaper or watching
Feeling down, depressed or hopeless
 
Feeling tired or little energy
Poor appetite or overeating
 
Thoughts that you would be better off dead or hurting
Feeling bad about yourself or that you are a failure or have let yourself of your family down.
 
Moving or speaking slowly that other people may notice ? OR being so fidgety or restless that you have been moving around a lot more than usual.
* * *
  Sleep Related  
Have you been bothered by any of the following problems over the past two weeks ?

1.
Is your sleep refreshing ?
2.
Do you awake in the middle of your sleep ?
3.
If yes, Howlong are you awake ?
4.
Do you use medication regularly to help you get sleep ?
If Yes, What?
5.
Do you use non-prescription drugs or alcohol to help you sleep ?
If Yes, What?
6.
What time do you usually go to bed ?
7.
What time do you usually get up ?
8.
Do you sleep longer on the weekend ?
9.
Do you sleep better away from home ?
10.
In a 24 hour period, what is the total number of hours of sleep you usually get ?
11.
How long does it take you to fall asleep ?
12.
How long do you lie awake in bed, before getting up ?
13.
How many naps per day do you take ?
14.
What are the average lengths of naps ?
15.
How many caffeinated beverages (coffee, tea, soda) do you drink per day ?
16.
How many hours before you go to bed, do you drink your last caffeinated beverage ?
17.
Have you ever had seizures or epilepsy ?
18.
Do your relatives have sleep problems ?
19.
Have you ever had a sleep study before ?
20.
Have you ever done shift work ?
If Yes, type of shift and how long ago ?
21.
Have you ever been treated or being treated for Hypertensions ?
22.
My desire or interest in sex is less than it used to be ?
23.
My sleep disturbs my bed partner's sleep ?
24.
I am told I snore in my sleep ?
25.
I am told I stop breathing in my sleep ?
26.
I suddenly wake up from my sleep gasping for air ?
27.
I have or have been told I have restless legs ?
28.
I feel tired upon awakening and want to go back to bed ?
29.
I get very sleepy when I should be awake and have to struggle to stay awake ?
30.
How often do you find yourself unable to fall asleep in the middle of your sleep ?
31.
Do you have headaches in the morning on awakening ?
32.
Do you kick your bed partner or the bed clothes off while you are asleep ?
33.
Have you had episodes of sudden muscular weakness or inability to move when laughing ?
34.
Do you experience vivid dream-like scenes while falling asleep ?
35.
Do you have daytime sleepiness ?
36.
Do you have unusual behavior during sleep ?
37.
Have you been told that you have violent behavior while you are asleep ?
38.
Do you awake from sleep screaming and your heart pounding ?
39.
Do you fall asleep screaming and your heart pounding ?
40.
If you were to pick a number between 1 (no problem at all) and 10 (extremely distressing), what number best describes how important the problems related to your sleep are to you ?

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