SLEEP HISTORY
Patient Details:
First Name:   *
Last Name:   *
DOB:
(MM/DD/YYYY)
       * 
Gender: * 
Practice Name: * 
Symptoms: check all symptoms you experience, or have been told about:









Sleepiness symptoms (Epworth sleepiness scale):
Sitting and reading
Watching TV
Sitting inactive in a public place
Laying down to rest in the afternoon
Traveling in car for 1 hour, but not engaged in driving
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped at a traffic light
Post-Sleep Questionnarie
How long did you sleep last night?(In hours)
Was this the same, shorter, or longer than usual?
How long did it take for you to fall asleep last night?(In hours)
Was this the same, shorter, or longer than usual?
How many times did you wake up last night?
How long were you awake during the night?(In hours)
Did you have difficulty returning to sleep?
If yes why?
Was last night sleep better, worse, or the same as usual?
Did you have any problems sleeping in the lab?
If yes please describe
Any other comments?

Bedtime Questionnarie
How long did you sleep last night?(In hours)
Did you take a NAP today?
what time
How Long
Prior to coming to sleep center, has today been unusual in any way?
Did you have the following today?
        
what time
How Much(in cups)
       
what time
How Much(in cups)
  
what time
How Much(in cups)
What medication have you taken today?
Medication Amount Time Taken
Do you have any physical complaints right now?
If yes please explain
Usual bedtime:
Usual waketime: