Sleep Questionnaire
Sleep QuestionnaireName: _______________________________Sex: ________Age: _____Date: ________Date of birth: _________________Height: ________Weight: _______Neck size: ________Referring Physician: ___________________Primary Care MD: _______________________MAIN Sleep CS Tr ouble falling asleep Trouble remaining asleep Excessive sleepiness during the day Snoring Unwanted behaviors during Sleep , such as ______________________________________ Other, explain ________________________________________ ____________________ How long? ________________________________________ ______________________PRIOR Sleep DISORDER DIAGNOSI S OR STUDIES I have a prior Sleep diagnosis of ________________________________________ ______Prior Sleep studies (where, when) ________________________________________ _______I am currently prescribed CPAP or Bilevel pressure.
breathing q es Y q No I have been told that I snore q loudly. q es Y q No I have been told that I stop breathing while asleep. q es Y q No I have been told that I snore only when sleeping on my back. q es Y q No I have been awakened by my own snoring. q es Y q No I awaken at night choking or gasping for air.
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