1667 N. Clyde Morris Blvd. St #2

Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E. Vera Endocrine Associates, Inc.

1667 N. Clyde Morris Blvd. St #2

Daytona Beach, FL32117

Ph: (386) 274-1414 Fax: (386) 274-2215

SLEEP QUESTIONNAIRE

Name ______Age ______D.O.B._____/_____/_____
Height ______Weight ______F M BMI ______Waist ______
(We will fill that in)

1. Do you get enough sleep? YES ______NO ______

2. Do you sleep: < 6 hrs 7-8 hrs > 9 hrs ______

3. Do you have Insomnia? YES _____ NO ______

If yes, please answer:

3.1 Does it take you more than 30 minutes to fall asleep? YES ___ NO ___
3.2 Interrupted Sleep/ Frequent Awakening? YES ___ NO ___
3.3 Inability to fall back to sleep? YES ___ NO ___
3.4 Early Awakening? YES ___ NO ___
3.5 Poor Sleep in General? YES ___ NO ___

4. Do you wake up tired / with tiredness? YES ___ NO ___

5. Do you haveexcessive daytime sleepiness? YES ___ NO ___

If yes, please complete attachment titled “Table A – The Epworth Scale”.

6. Do you snore? YES ___ NO ___

If yes, please complete attachment titled “Table B – The Berlin Questionnaire”.

7. Do you stop breathing while sleeping (apnea)? YES ___ NO ___

If yes, are you on a CPAP machine?
YES _____ NO _____ OTHER DEVICE (pls. specify) ______

8. Is your neck circumference

______< 17 inches ______> 17 inches

9. Do you have or have you been diagnosed with

High Blood Pressure / Depression
Diabetes Mellitus / Anxiety
Heart Disease / Impotence
Stroke / Loss of Libido (Sexual Appetite)
Respiratory (Lung) Problems / Obesity
Thyroid Disease / Parathyroid / Calcium Disorder
Pituitary/Hypophysis Disorder / Other

Female patients: Please see questionnaire on reverse. Thank you.

Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E. - Daytona Beach, FLPage 2

Questions for Women

Your Name:Date:

W1:W2: Are you on Birth Control Pills?

Is your menstrual cycle normal?YesNoYes ______No ______

Date of last menstrual period:// Did you take Birth Control Pills from

Date of first menstrual period”// ______until ______years of age.

W3:W4:

Have you been pregnant? Yes No Menopause (please indicate if applicable):

Do you have children or complete pregnancy?Yes No Spontaneous/Natural (years of age)

Surgical/Oophorectomy (years of age)

W3:

Hormonal Replacement (please circle and indicate duration):

PillsCreamRingPatchesInjectionsOther

Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E. - Daytona Beach, FLPage 3

Table A - Epworth Sleepiness Scale

Your Name:Date:

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

Even if you have not done some of these things recently, try to work out how they would have affected you.

This refers to your usual way of life in recent times.

Use the following scale to choose the most appropriate number for each situation.

Please circle:

0 = would never doze off

1 = slight chance of dozing off

2 = moderate chance of dozing off

3 = high chance of dozing off

Situation:Chance of dozing off:

Sitting and reading0123

Watching TV0123

Sitting, inactive ina public place (theater or meeting) 0123

As a passenger in a car for an hour without a break0123

Lying down to rest in the afternoon when circumstances permit0123

Sitting and talking to someone0123

Sitting quietly after a lunch without alcohol0123

In a car, while stopped for a few minutes in traffic0123

Total:

Scale:

0 to 8 = Normal

9 to 11 = Borderline sleepiness

12 to 16 = Excessive sleepiness

17 to 24 = Severe sleepiness

Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E. - Daytona Beach, FLPage 4

Table B - Berlin Questionnaire

BMI:Your Name:Date:

1.Do you snore?YesNoDon’t know

2.You snoring is:

Slightly louder than breathingAs loud as talking

Louder than talking Very loud – can be heard in adjacent rooms

3.How often do you snore?

Nearly every day 3 – 4 times per week