Sleep Management Institute (Sleep History)

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		Provider Name

Gender

Male

Female

Race

African-American

Hispanic

Asian or Pacific Islander

Caucasian / White

American Indian / Native American

Marital Status

Single

Married

Divorced

Separated

Widowed

Number of Marriages

Number of Children

8 or more

What is your height?

Feet

What is your current weight?

What is your previous weight? (one year ago)

What is the highest grade you finished in school?

Grades 1-8

Grades 9-11

High school graduate / GED equivalent

Junior college / vocational degree

Some college (less than 4 years)

College degree

Advanced degree (Masters, PhD, MD, JD)

Do you have military experience?

Yes

Employment History

How would you describe your Employment?

Homemaker

On disability

Unemployed

Retired

Full time

Part time

Occupation:

Do you have any of the following job requirements?

Work rotating shifts

Work night shift

Travel across time zones

Driving a vehicle

Work with dangerous equipment or in hazardous situations

Work with hazardous substances

None of the above

What is your sleep problem?

Difficulty falling asleep

Difficulty staying asleep

Stop breathing while asleep

Excessive daytime sleepiness

Excessive fatigue

Snoring

Unusual behaviors during sleep or during awakenings from sleep

Sleeping more now than a year ago

Other:

Is your sleep problem

Getting better

Getting worse

Staying the same

Who INITIALLY suspected a sleep problem?

You

Your spouse / bed-partner / roommate

Your physician

Do you currently have a bed partner/roommate?

Yes

Have you ever had a sleep study before?

Yes

Because of your sleep problems, have you:

Considered (or are on) disability?

Yes

Had work (or school) difficulties?

Yes

Had motor vehicle accidents?

Yes

Had driving problems?

Yes

Marital or social problems?

Yes

Drug or alcohol use?

Yes

Had an injury?

Yes

The following questions are related to your sleep during the past few months.

WEEKDAYS

When do you usually go to sleep?

When do you usually wake up?

Do you use an alarm to awaken?

Yes

WEEKENDS

When do you usually go to sleep?

When do you usually wake up?

Do you use an alarm to awaken?

Yes

How many hours do you try to sleep?

How long do you actually sleep?

How satisfied are you with your… (1 = Very Satisfied, 7 = Very Dissatisfied)

Current sleep quality?

Current daytime alertness?

Ability to feel rested after your night's sleep?

How long do you lay in bed before falling asleep?

less than 15 min

15-30 min

31-45 min

46-60 min

greater than 1 hr

How many times do you typically awaken during the night?

Once or less

2 to 3

4 to 5

6 or more

How many times do you typically awaken to use restroom?

Once or less

2 to 3

4 to 5

6 or more

What is the total time you are unable to sleep between bedtime and your final wake-up time:

less than 15 min

15-30 min

31-45 min

46-60 min

more than 1 hr

When unable to sleep, do you do any of the following:

Watch TV or listen to music or radio in bed

Eat

Read

Use computer or internet

Worry at night

Other:

Describe any problems in your sleeping environment:

Uncomfortable temperature

Noisy room

Excessive light

Bed partner interrupts sleep

Uncomfortable bed

Pet interference

Other:

Do you take naps or doze off during the day?

Yes

Do your legs have a “creepy, crawling” sensation while sitting or lying quietly that causes an almost irresistible urge to move your legs?

Yes

How often do you (or your bed partner/roommate) find that you:

Snore so loudly that it would bother others near you

Never

Rarely

Sometimes

Often

Usually

Always

Sleep apart from your bed partner or roommate because of snoring

Never

Rarely

Sometimes

Often

Usually

Always

Make unusual sounds while sleeping

Never

Rarely

Sometimes

Often

Usually

Always

Have trouble breathing at night

Never

Rarely

Sometimes

Often

Usually

Always

Awaken choking, gasping or smothering

Never

Rarely

Sometimes

Often

Usually

Always

Awaken coughing

Never

Rarely

Sometimes

Often

Usually

Always

Have others say that you stop breathing in your sleep

Never

Rarely

Sometimes

Often

Usually

Always

Are bothered by physical problems, sensations or pain at night

Never

Rarely

Sometimes

Often

Usually

Always

Awaken with dry mouth and/or sore throat

Never

Rarely

Sometimes

Often

Usually

Always

Have palpitations or chest pain at night

Never

Rarely

Sometimes

Often

Usually

Always

Awaken during the night or in the morning with a headache

Never

Rarely

Sometimes

Often

Usually

Always

Are awakened with hot flashes or sweating

Never

Rarely

Sometimes

Often

Usually

Always

Have twitches, jerks or startled movements during sleep

Never

Rarely

Sometimes

Often

Usually

Always

Have restless sleep or awaken with bedclothes or sheets in a mess

Never

Rarely

Sometimes

Often

Usually

Always

Sit up and scream while asleep or suddenly wake up scared

Never

Rarely

Sometimes

Often

Usually

Always

Talk while sleeping

Never

Rarely

Sometimes

Often

Usually

Always

Walk or eat while asleep, with no recall of this the next day

Never

Rarely

Sometimes

Often

Usually

Always

Act out your dreams

Never

Rarely

Sometimes

Often

Usually

Always

Afraid to be alone at night

Never

Rarely

Sometimes

Often

Usually

Always

Grind teeth while sleeping

Never

Rarely

Sometimes

Often

Usually

Always

Wet the bed

Never

Rarely

Sometimes

Often

Usually

Always

Are tired and fatigued even when you are not sleepy

Never

Rarely

Sometimes

Often

Usually

Always

Doze or nod off while at work

Never

Rarely

Sometimes

Often

Usually

Always

Doze or nod off while driving

Never

Rarely

Sometimes

Often

Usually

Always

Feel sleepy and drowsy all day

Never

Rarely

Sometimes

Often

Usually

Always

Wake up tired or NOT rested

Never

Rarely

Sometimes

Often

Usually

Always

Feel tired or sleepy in the morning

Never

Rarely

Sometimes

Often

Usually

Always

Feel tired or sleepy during the afternoon

Never

Rarely

Sometimes

Often

Usually

Always

Feel tired or sleepy in the early evening

Never

Rarely

Sometimes

Often

Usually

Always

Are more awake and alert in the evening than morning

Never

Rarely

Sometimes

Often

Usually

Always

Wake up and are alert in the morning before it is time to get up

Never

Rarely

Sometimes

Often

Usually

Always

Sleep longer on weekends or holidays than on weekdays

Never

Rarely

Sometimes

Often

Usually

Always

Have trouble falling asleep at your usual bedtime

Never

Rarely

Sometimes

Often

Usually

Always

Have trouble staying asleep after you have fallen asleep

Never

Rarely

Sometimes

Often

Usually

Always

Awaken early in the morning and have trouble getting back to sleep

Never

Rarely

Sometimes

Often

Usually

Always

Lie awake at night with thoughts racing through your mind

Never

Rarely

Sometimes

Often

Usually

Always

Are too full of energy or have many exciting/important things to do to sleep

Never

Rarely

Sometimes

Often

Usually

Always

Have frightening dreams or nightmares

Never

Rarely

Sometimes

Often

Usually

Always

Have vivid dreams shortly after falling asleep

Never

Rarely

Sometimes

Often

Usually

Always

Heard a voice or saw things like a vision while falling asleep or awakening

Never

Rarely

Sometimes

Often

Usually

Always

Felt paralyzed, totally unable to move, but mentally alert while falling asleep or wakening

Never

Rarely

Sometimes

Often

Usually

Always

Have sudden physical weakness of arms, legs or face when laughing, crying, or during other emotional situations without dizziness

Never

Rarely

Sometimes

Often

Usually

Always

Are refreshed and awake even after short (10-15 min) naps

Never

Rarely

Sometimes

Often

Usually

Always

Use alcohol to help you sleep

Never

Rarely

Sometimes

Often

Usually

Always

Use sleeping pills to help you sleep

Never

Rarely

Sometimes

Often

Usually

Always

Use medicine to help you stay awake

Never

Rarely

Sometimes

Often

Usually

Always

Use coffee, tea, cola or other stimulants to help you stay awake

Never

Rarely

Sometimes

Often

Usually

Always

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Oklahoma City, OK 73189
Form Number 213

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