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:
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:
