Great Hills ENT Sleep QuestionnaireVisit Date:______
Mark T Brown, MD
Patient: ______Date of Birth:______
Please answer all of the following questions.
What time do you normally go to bed? ______
How many hours do you sleep on a normal night? ______
Do you sleep: ☐ alone☐ with a partner?
Do you sleep better ☐ during the week ☐ on the weekend☐ does not matter.
How long have you been having sleep problems?
☐ lifetime ☐years ☐ months ☐ weeks
Have you been diagnosed with a sleep disorder? ☐Which one(s)?______
List any medications you have taken in your life to help with your sleep: ______
______
List any medications you have taken that have helped with your sleep: ______
______
Has anyone in you family with a sleep disorder? ☐no ☐ yes. If yes, please describe their sleep problems. ______
______
-Do you have trouble:☐ going to sleep☐ wakening in the middle of the night☐ waking up too early
-Do you do any of the following activities in bed:
☐read☐ watch TV☐ use computer/tablet☐ listen to music☐ use your phone
-Do you have any of the following when trying to fall asleep or awakeningtoo early:
☐anxiety☐ worries ☐ anger/frustration ☐ sadness ☐racing thoughts
-If you awaken in the middle of the night do you:
☐ lie in bed ☐ get out of bed ☐ eat ☐ drink☐ take a pill☐ use the bathroom
-Over the last 2 weeks, how often have youNot at allSeveral daysMore than ½ Every day
been bothered by the following problems?of the days
- Feeling nervous, anxious, or on edge 0 1 2 3
- Not being able to stop or control
worry 0 1 2 3
- Little interest or pleasure in doing
things 0 1 2 3
- Feeling down, depressed, or
hopeless 0 1 2 3
TOTAL SCORE ______
-Do you now or have you ever had any of the following occur when you are falling asleep, asleep, or waking up?
☐ sleep walk☐eat in your sleep☐ sleep talk
☐ seeing or hearing something that is not there☐ feel paralyzed☐ have nightmares
☐hear loud noises in the head☐ grind your teeth☐ wet the bed
☐unknowingly awaken screaming ☐ actout dreams☐ kick rhythmically in bed
-When you try to relax in the evening or sleep at night, do you ever have unpleasant, restless feelings in your legs that can be relieved by walking or movement? ☐
-How often are you unable to fall asleep?
1. Never2. Rarely3.Sometimes4.Often5. Almost always
(< once/month)(1-2X/month)(1-2X/week)
-How often you feel bad or not well rested in the morning?
1. Never2. Rarely3.Sometimes4.Often5. Almost always
(< once/month)(1-2X/month)(1-2X/week)
PLEASE CONTINUE TO THE NEXT PAGE.
-How often do you take a nap during the day?
1. Never2. I would like3. 1-2X/week4. 3-5X/week5. Almost daily
to, but cannot
-How often have you had weak knees/buckling knees during emotions like laughing , happiness, or anger?
1. Never2. Rarely3.Sometimes4.Often5. Almost always
(< once/month)(1-2X/month)(1-2X/week)
-How often have you experienced sagging of the jaw during emotions like laughing, happiness, or anger?
1. Never2. Rarely3.Sometimes4.Often5. Almost always
(< once/month)(1-2X/month)(1-2X/week)
-How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:0 = no chance 1 = slight chance 2 = moderate chance 3 = high chance
SITUATIONCHANCE OF DOZING
Sitting and reading_____
Watching TV_____
Sitting inactive in a public place (e.g. a
theater or a meeting)_____
As a passenger in a care for an hour without a break_____
Lying down to rest in the afternoon when
circumstances permit_____
Sitting and talking to someone_____
Sitting quietly after lunch without alcohol_____
In a car, while stopped for a few minutes in traffic_____
TOTAL SCORE_____
-Do you experience pain at night? ☐Where?______
☐ How frequently? ______
-Have you recently been ill or hospitalized? ☐No ☐Yes. Explain ______
-Are you having increased stress or trouble in any of the following places or situations?
☐Work☐School
☐Home☐Relationships
☐Place of Worship☐Family
-Do you travel for work? ☐Frequency? ______Across time zones? ______
-If you had no schedule to follow and could choose freely, what time would you go to bed? ______
-If you had no schedule to follow and could choose freely, what time would you go to get up? ______
-How often do you exercise? ☐Daily ☐Several times a week ☐ Weekly ☐Occasionally ☐Never
-What time of day do you exercise, if you do? ______
Please check all symptoms that apply from the list below:
☐tiredness (fatigue)☐sleepiness,
☐difficulty concentrating☐moodiness
☐attention or memory problems☐proneness to errors or accidents
☐social or academic performance problems☐ongoing concerns or worries about sleep
Any other concerns?______
______
X ______
Patient (or guardian) Signature