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Sleep questionnaire

Discussion in 'Patient Data Repository & Treatment Review Project' started by Cort, Jun 4, 2010.

  1. Cort

    Cort Phoenix Rising Founder

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    Raleigh, NC
    Questionnaire on Sleep - taken from researchers questionnaires provided to us. (Any other sleep questionnaires we can look at?)

    10. In the last 4 weeks, how often have you taken medication to improve your sleep?
    □ Not at all
    □ A few times
    □ Several times
    □ Many times

    11. In the last 4 weeks, about how many nights have you had a bad sleep?

    □ 5 or less
    □ 6 to 15
    □ 16 to 25
    □ More than 25

    12. In the last 4 weeks, about how many hours sleep did you have on your good nights?

    □ 5 or less
    □ 6
    □ 7 or 8
    □ 9
    □ 10 or more

    13. In the last 4 weeks, about how many hours sleep did you have on most of your bad nights?

    □ 5 or less
    □ 6
    □ 7 or 8
    □ 9
    □ 10 or more

    14. In the last 4 weeks, how much of a problem have you had with each of the following?

    None A little Some A good bit A great deal
    Waking without feeling rested 1 2 3 4 5
    Trouble falling asleep 1 2 3 4 5
    Waking too early in the morning 1 2 3 4 5
    Frequent awakening during the night 1 2 3 4 5

    Questions about Sleep

    10. In the last 4 weeks, how often have you taken medication to improve your sleep?
    □ Not at all
    □ A few times
    □ Several times
    □ Many times


    12. In the last 4 weeks, about how many hours sleep did you have on your good nights?

    □ 5 or less
    □ 6
    □ 7 or 8
    □ 9
    □ 10 or more

    13. In the last 4 weeks, about how many hours sleep did you have on most of your bad nights?

    □ 5 or less
    □ 6
    □ 7 or 8
    □ 9
    □ 10 or more

    14. In the last 4 weeks, how much of a problem have you had with each of the following?

    None A little Some A good bit A great deal
    Waking without feeling rested 1 2 3 4 5
    Trouble falling asleep 1 2 3 4 5
    Waking too early in the morning 1 2 3 4 5
    Frequent awakening during the night 1 2 3 4 5


    Additions?

    When do you usually fall asleep?
    When do you usually wake up?
    Besides your main sleep period - if you sleep during the day how many hours do you sleep?

    Sleep Disorder Questionnaire from Portland Clinichttp://www.theportlandclinic.com/specialties/sleep-center


    Symptoms

    Snoring _____ Breathing stops during the night _____
    Difficulty falling asleep _____ Difficulty staying asleep during the night _____
    Sleepiness or feeling tired _____ Bed partner making you seek help _____
    Other:

    SLEEP ENVIRONMENT
    Yes No
    Do you usually sleep in the same bed every night
    Do you watch TV, read in bed or use a computer before sleep?
    Does your partner often disrupt your sleep?
    Is your bed comfortable

    SLEEP- WAKE SCHEDULE

    Do you keep a fairly regular schedule?

    What time do you go to bed on weekdays? AM / PM, Weekends

    What time do you wake up on weekdays? AM / PM Weekends

    Do you drink alcohol before going to bed?

    Once in bed, how long does it take to fall asleep?

    Once asleep, how many times do you wake up?

    What causes you to wake up?

    Do you get up multiple times to go to the bathroom?

    Total number of hours of sleep

    Do you awaken refreshed? Always Sometimes Never

    How often do you take naps?

    Daily A few days a week A few days a month Rarely/never

    If you nap, how long are your naps?

    SLEEP SYMPTOMS
    Always Sometimes Never
    Difficulty falling sleep
    Trouble staying asleep
    Repeated awakenings
    Waking up too early
    Snoring or difficulty breathing
    Choking or gasping
    Morning headaches
    Dry Mouth

    Always Sometimes Never
    Tired or crampy legs when you awaken
    Leg, arm, or body jerks
    Unpleasant feelings in arms or legs when you awaken
    Irresistible desire to move legs
    Intense visual images when falling asleep
    Sleep talking
    Sleep walking
    Other behaviors

    AWAKENING SYMPTOMS

    Always Sometimes Never
    Wake up short of breath
    Coughing or choking
    Rapid heart beat
    Heartburn
    Nasal congestion
    Dry mouth
    Headache
    Anxious or panicky feeling
    Legs, arms or body moving or jerking
    Bed covers extremely messy
    Vivid or frightening images
    Temporarily unable to move your body
    Momentary confusion

    DAYTIME SYMPTOMS
    Always Sometimes Never
    Feeling tired or sleepy during the day
    Struggling to stay awake
    Often feel brain fog or in a daze
    Feeling sleepy while driving
    Falling asleep in mid-conversation
    Trouble focusing on work
    Difficulty remembering
    Sudden muscular weakness with strong emotion
    Muscle weakness during intense emotion
    Feeling sad, depressed, anxious or irritable


    REVIEW OF SYMPTOMS (CHECK ALL THAT APPLY)

    Weight gain Shortness of breath Feeling depressed
    Coughing Urinary frequency Feeling anxious
    Wheezing Erectile dysfunction Heartburn
    Chest pain Pain in muscles Ankles swelling
    Palpitations Pain in joints Abdomen discomfort

    FAMILY HISTORY OF SLEEP DISORDERS
    Problem Relationship
    Insomnia
    Daytime sleepiness
    Restless leg syndrome
    Narcolepsy
    Sleep apnea
    Habitual snoring

    EPWORTH SLEEPINESS SCALE
    0 1 2 3
    Would never doze Slight chance Moderate chance High chance

    Sitting and reading 0 1 2 3
    Watching television 0 1 2 3
    Sitting inactive in a public place for example, a theater or a meeting 0 1 2 3
    As a passenger in a car for an hour without a break 0 1 2 3
    Lying down to rest in the afternoon 0 1 2 3
    Sitting quietly after lunch (when youve had no alcohol) 0 1 2 3
    Sitting and talking to someone 0 1 2 3
    In a car, while stopped in traffic 0 1 2 3

    BED PARTNER QUESTIONS?
    Do you have a regular bed partner:

    If possible, please have your bed partner (or anyone who observed you sleep recently) help answer the questions below.
    When asleep, do others observe: Always Sometimes Never
    Snoring
    Loud breathing or sighing
    Breathing becomes labored
    Long pauses between breaths
    Repeated moving of arms, legs, or body
    Teeth grinding
    Sleep walking
    Sleep talking
    Acting out dreams

    Do any of the above result in sleeping in separate beds?

    Use the space below to have your bed partner describe any additional information, concerns, or problems they feel should be included for evaluation:


    Has this patient ever fallen asleep during normal daytime activities or in dangerous situations? If yes, please explain:
  2. ahimsa

    ahimsa Senior Member

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    I have a questionnaire from a sleep center. It may take me a while (it's 5? 6? pages) but I promise to enter the information one of these days.

    I'll try not to forget but just in case, if a couple of weeks go by, and there's no input from me, send me a reminder. :Retro wink:

    Marjorie
  3. Cort

    Cort Phoenix Rising Founder

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    that would be great Marjorie....I'll buzz you in a couple of days, actually.
  4. ahimsa

    ahimsa Senior Member

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    Oregon, USA
    Okay, I found the documents I was looking for - that's always the hardest part! There's a 5 page "Sleep Disorder Questionnaire" and a 1 page "Sleep Log" (with columns for 7 days worth of sleep information).

    Fortunately, before I started trying to type in the information from the forms, I realized that these both documents are available online at

    http://www.theportlandclinic.com/specialties/sleep-center

    There's one link for the Sleep Disorder Questionnaire and another for the Sleep Log .

    FYI, both files are in Word 97 format. I have no idea why they are not PDF files. Let me know if you can't read the files and I can find another way to get them to you.

    Marjorie
  5. Cort

    Cort Phoenix Rising Founder

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    Very nice! Thanks :)

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