Date:

Patient’s Name: Birth date: Age:

Height: Weight: Neck size Sex: M F

Phone Number: Occupation:

Name of Referring Physician(s):

Phone:

Phone:

Reason for referral:

How long have you been bothered by this problem?

SLEEP HISTORY

Your Bedtime in Weekdays Weekends and Holidays

Your Wake up time on Weekdays Weekends

How long it will take you to fall asleep?

How much time do you spend in the bed after waking up in the morning?

Total sleep time: Night? Naps?

About falling asleep: Do you feel or suffer frequently from the following:

Restless sleep? Yes No Difficulty initiating sleep? Yes No

Tingling, creepy, or crawling sensation in your legs at rest? Yes No

The urge to move your legs after that? Yes No

Moving your legs will eliminate this discomfort? Yes No

Feeling unable to move your legs/arms at sleep or wake up time? Yes No

Seeing frightening “dreams” at sleep or wake up time? Yes No

Racing thoughts in your mind? Yes No

Feeling depressed or sad? Yes No

Feeling Anxious? Yes No

Feeling muscular tension? Yes No

Being afraid of dark or anything else? Yes No

Having any kind of pain or discomfort? Yes No

DURING SLEEP:

Do You:

Wake up from sleep? Yes No

How often?

WHY?

Snore? Y N Loud? Y N

Pause or stop breathing? Y N

Struggle to breathe? Y N

Breathe through your mouth? Y N

Wake up Choking? Y N

Walk in your sleep? Y N

Talk in your sleep? Y N

Wake up screaming, violent or confused? Y N

Kick with your legs? Y N

Have dream like images when waking up ? Y N

Have unusual Movements while asleep? Y N

Grind your teeth? Y N

ABOUT WAKING UP:

Do You Wake up:

With headache? Y N

Sleepy? Y N Tired? Y N

With dry mouth? Y N

DURING THE DAY:

Do you:

Feel Unrefreshed when waking up? Y N

Feel sleepy? Y N Feel tired? Y N

Feel sleepy while inactive (Watching TV, Reading, etc.)? Y N

Feel unable to concentrate? Y N

Have difficulty sustaining attention? Y N

Feel Unable to remember things? Y N

Doze off in a meeting? Y N

Doze off driving? Y N

Feel depressed, sad, or irritable? Y N

Feelings of guilt, hopelessness? Y N

Have Decreased or loss of appetite? Y N

Have you ever noticed loss of muscle tone after emotional changes such as:

Fear, anger or excitement? Y N

Do you feel the irresistible urge to sleep? Y N

Any Current Medical Problem?

Past Medical History:

Previous Surgery(s):

ANY CURRENT MEDICATIONS/ INHALAR? SPRAYS: Y N

NAME, Time and Reason you take it

Please list the name of any pills for SLEEPING or to help you STAY AWAKE :

Name Does it help?:

Y N

Y N

Y N

Allergy to medicine:

Family History:

Sleep Apnea? Sleep Walking? Sleep Terror? Nightmare?

Bed Wetting? Narcolepsy? Seizure? Stroke?

Heart attack? High blood pressure? Acid reflux?

Hay fever?

Personal Habits:

Do you smoke? Y N

If yes how many cigarettes/day?

Do you drink Alcohol? Y N

IF YES; how often?

When do you drink?

Any recreational drugs? Y N

Do you drink coffee/tea in the afternoon? Y N

How much? What time?

Any history of weight change? Gain Loss

How much?

Over How Long?

Other Comments: