Transcription of Sleep Questionnaire
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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. Settings _____Oxygen during the day or night _____ liters per minute. Yes No I have had surgery for a Sleep disorder UPPP Tonsillectomy.
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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