Monday, Tuesday, Wednesday, or Thursday ___________(date), at ________(time).
Your appointment with the sleep physician will last approximately 30 minutes. Please complete the attached questionnaire and bring it with you to your appointment.
The Sleep Center is located in the Jack V. Fuller House at 1600 H Street in Springfield. It is a blue house just east of McKenzie-Willamette Hospital, across the street from the Medical Office building. Free parking is available at the Fuller House. The main entrance to the Sleep Center is on the opposite side of the building from the parking lot. However, the back door is often unlocked. If you cannot make your appointment please call us at 744-8525 or call the scheduling center at 744-6000.
We look forward to seeing you!
Sleep Disorders Questionnaire (5 parts)
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Name: |
Date of Birth: |
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Today’s Date: |
Your Height: |
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Major Complaint: |
Your Weight: |
Instructions:
This questionnaire will give your doctor a good understanding about your problems with sleeping and waking. It is very important to answer every question because some disorders show up as a pattern of answers to different questions
In answering the questions, consider each question as applying to the past six months of your life, unless you have been instructed to use a different period of time by the person who gave you this questionnaire.
Some people work night shifts or rotating shifts. Others have a very changeable bedtime. For these people, questions that ask about “day, daytime, morning, etc.” will mean the time when they wake from their longest sleep of the day and become active. Similarly “night, nighttime, bedtime, nocturnal” will refer to whatever time of the day it is that they are having their longest sleep of the day.
Most of the questions are simple statements. You answer by circling a number from 1 to 5. If you strongly disagree with the statement, or if it never happens to you, answer “1”. If the statement is always true in your case, or you agree strongly with it, answer “5”. You may also choose “2 rarely”, “3 sometimes”, or “4 usually” as your answer. Notice that an “answer key” appears at the bottom of each page to remind you what the numbers means. Please answer all of the questions.
If you are certain that a question does not apply to you, leave it blank. But… try to answer every question if at all possible. This is important. Notice that the answer “1” can mean that the things in the question never happen to you.
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11) I am told I snore loudly and bother others. |
1 2 3 4 5 |
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22) I am told I stop breathing (“hold my breath”) in sleep |
1 2 3 4 5 |
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33) I awake suddenly gasping for breath, unable to breathe. |
1 2 3 4 5 |
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44) I sweat a great deal at night. |
1 2 3 4 5 |
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55) I have high blood pressure (or once had it). |
1 2 3 4 5 |
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66) I have a problem with my nose blocking up when I am trying to sleep (allergies, infections). |
1 2 3 4 5 |
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77) My snoring or my breathing problem is much worse if I sleep on my back. |
1 2 3 4 5 |
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88) My snoring or my breathing problem is much worse if I fall asleep right after drinking alcohol. |
1 2 3 4 5 |
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99) When falling asleep, I feel paralyzed (unable to move). |
1 2 3 4 5 |
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110) I feel unable to move (paralyzed) after a nap. |
1 2 3 4 5 |
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111) I have dream-like images (hallucinations) when I awaken in the morning even though I know I am not asleep. |
1 2 3 4 5 |
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112. I have slept for several days at a time, or at least I have been overwhelmingly sleepy for that long. |
1 2 3 4 5 |
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113. Now, I am very sleepy during the day and I struggle to stay awake. |
1 2 3 4 5 |
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114. In the past 6 months, I have fallen asleep accidentally in some of these situations: eating a meal, talking on the phone, talking to someone, riding in a bus or car, watching TV, at a theater, reading a book, at a lecture. |
1 2 3 4 5 |
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115. I got bad grades in school because I was too sleepy. |
1 2 3 4 5 |
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116. I now have trouble doing my job because of sleepiness or fatigue. |
1 2 3 4 5 |
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117. I often have to let someone else drive the car because I am too sleepy to do it. |
1 2 3 4 5 |
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118. I see vivid dream-like images (hallucinations) either just before or just after a daytime nap, yet I am sure I am awake when they happen. |
1 2 3 4 5 |
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119. I am often unable to move (paralyzed) when I am waking up in the morning. |
1 2 3 4 5 |
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220. Sometimes I realize I have driven my car to the wrong place and I can’t remember how I did it. |
1 2 3 4 5 |
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221. I get “weak knees” when I laugh. |
1 2 3 4 5 |
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222. I get sudden muscular weakness (or even a brief period of paralysis, being unable to move) when laughing, angry, or in situations of strong emotion. |
1 2 3 4 5 |
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223. At bedtime, I worry about things. |
1 2 3 4 5 |
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224. My sleep is disturbed by worrying about things. |
1 2 3 4 5 |
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225. At bedtime, I feel muscle tension. |
1 2 3 4 5 |
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226. At bedtime, I’m afraid of not being able to sleep. |
1 2 3 4 5 |
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227. After waking at night, I fear I will not be able to get back to sleep. |
1 2 3 4 5 |
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228. I wake up in the morning with a headache. |
1 2 3 4 5 |
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229. I grind my teeth while I sleep. |
1 2 3 4 5 |
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330. My sleep is disturbed by pain in my neck, back, muscles, joints, legs, or arms. |
1 2 3 4 5 |
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331. I have trouble getting to sleep at night. |
1 2 3 4 5 |
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332. At bedtime, thoughts race through my mind. |
1 2 3 4 5 |
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333. At bedtime, I feel sad and depressed. |
1 2 3 4 5 |
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334. My sleep is disturbed by sadness or depression. |
1 2 3 4 5 |
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335. I have a lot of nightmares (frightening dreams). |
1 2 3 4 5 |
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336. I have been unable to sleep at all for several days. |
1 2 3 4 5 |
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337. I am unhappy about loving relationships in my life. |
1 2 3 4 5 |
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338. I have considered or attempted suicide. |
1 2 3 4 5 |
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339. Someone in my family has been hospitalized for a psychiatric illness or “nervous breakdown”. |
1 2 3 4 5 |
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440. I wake up often during the night. |
1 2 3 4 5 |
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441. When falling asleep, I have “restless legs” (a feeling of crawling, aching, or inability to keep legs still). |
1 2 3 4 5 |
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442. At night my heart pounds, beats rapidly, or beats irregularly (“palpitations”). |
1 2 3 4 5 |
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443. My sleep is disturbed by “restless legs” (a feeling of crawling, aching, inability to keep legs still). |
1 2 3 4 5 |
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444. I feel that I have insomnia. |
1 2 3 4 5 |
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445. My desire or interest in sex is less than it used to be. |
1 2 3 4 5 |
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446. I smoke tobacco within two hours of bedtime. |
1 2 3 4 5 |
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47. How long is your longest wake period at night? |
[ ] Less than 5 minutes
[ ] 6 to 19 minutes
[ ] 20-59 minutes.
[ ] 1-2 hours.
[ ] More than 2 hours |
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48. How many times in a night do you get up to urinate?
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[ ] None
[ ] One time
[ ] Two times
[ ] Three times
[ ] Four or more times |
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49. How many work accidents have you had as a result of sleepiness or fatigue?
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[ ] None
[ ] One time
[ ] Two times
[ ] Three times
[ ] Four or more times |
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50. What is your current weight (in lbs.)
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[ ] 134 lbs. or less
[ ] 135-159 lbs.
[ ] 160-183 lbs.
[ ] 184-209 lbs.
[ ] 210 lbs. Or more |
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51. How many years were you a smoker?
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[ ] None
[ ] 1 year
[ ] 2-12 years
[ ] 13-25 years
[ ] 26 years or more |
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52. How old are you now?
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[ ] 25 or under
[ ] 26-35 years
[ ] 36-44 years
[ ] 45-50 years
[ ] 51 years or older |
Sleep Disorders Questionnaire- Short Form: Version 010102: (APN 1-8, 50-52; NAR 9-22, 49; PSY 31-39; MYC 40-48)
SLEEP SOLUTIONS CENTER
THE EPWORTH SLEEPINESS SCALE
How
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, please indicate how they would have affected you. Use the following scale to choose the most appropriate number for each situation described.
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
SITUATIONS:
Sitting and reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________
Watching TV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________
Sitting inactive in a public place (a theater or a meeting) . . . . . . . . . . . ________
As a passenger in a car 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ________
Thank you for your assistance!!
Sleep Center Health & Family Questionnaire (v0801)
1. How would you rate your current general health?
__ very poor __ poor __ average __ good __ very good
2. In the table below, circle NOW, if you now have; or PAST, if you had in the past any of the following:
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Diabetes |
o Now |
o Past |
Anemia |
o Now |
o Past |
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High Blood Pressure |
o Now |
o Past |
Peptic Ulcers |
o Now |
o Past |
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Stroke |
o Now |
o Past |
Acid Reflux (Heartburn) |
o Now |
o Past |
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Heart Disease or CHF |
o Now |
o Past |
Kidney Disease |
o Now |
o Past |
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Heart Attack |
o Now |
o Past |
Thyroid Disease |
o Now |
o Past |
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Angina |
o Now |
o Past |
Arthritis |
o Now |
o Past |
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Emphysema or COPD |
o Now |
o Past |
Back Pain |
o Now |
o Past |
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Asthma |
o Now |
o Past |
Head Trauma |
o Now |
o Past |
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Tuberculosis |
o Now |
o Past |
Severe Headaches |
o Now |
o Past |
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Other Lung Disease |
o Now |
o Past |
Epilepsy (Seizures) |
o Now |
o Past |
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Nasal Allergies |
o Now |
o Past |
Passing out Spells (Fainting) |
o Now |
o Past |
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Runny or Blocked Nose |
o Now |
o Past |
Depression |
o Now |
o Past |
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Hormonal Problem |
o Now |
o Past |
Anxiety Disorder |
o Now |
o Past |
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Urological Problem |
o Now |
o Past |
Problems with Alcohol |
o Now |
o Past |
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Prostate Disease |
o Now |
o Past |
Problems with Drugs |
o Now |
o Past |
3. Please list hospitalizations. Please give the reasons for each hospitalization and the dates, as best you can remember.
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REASON FOR HOSPITALIZATION |
DATE |
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____________________________________________________________________ |
_____________________ |
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____________________________________________________________________ |
_____________________ |
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____________________________________________________________________ |
_____________________ |
4. Please give important details about your medical conditions
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
5. List your current average for each category below.
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Hours worked per day |
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Days worked per week |
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Days of vacation per year |
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Number of cigarettes smoked per day |
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Other tobacco used per day (pipe-fuls or cigars) |
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Cups of regular coffee per day |
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Cups of tea per day |
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Glasses of cola or other caffeinated beverages per day |
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Cans of beer per day (12 oz.) |
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Glasses of wine per day (3-4 oz.) |
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Alcoholic drinks per day (1-2 oz. straight or mixed) |
6. If you smoke or used to smoke…
What is the most you ever smoked? ___________ If you quit, how long ago did you quit? ___________
7. What is your current relationship status?
__ Single __ Married __ Divorced __ Widowed __ Separated __ Living with someone
8. How many times have you been married? _______
9. What is your occupation? ________________________________________________________
FAMILY INFORMATION
1. Is your father living? __ Yes __ No
If yes, how old is he? _______ If no, at what age did he die? _____ What caused his death? _______________________________What was your father’s major occupation?
___________________________________________________________________________
2. Is your mother living? __ Yes __ No
If yes, how old is she? _______ If no, at what age did she die? _____ What caused her death? ______________________________What was your mother’s major occupation?
____________________________________________________________________________
3. Do any of your brothers and sisters (if applicable) have any major diseases or sleep disorders?
_____ If yes, please describe: ______________________________________________
______________________________________________________________________
SLEEP CENTER MEDICATION QUESTIONNAIRE
We need to know what drugs, vitamins, and herbal substances you have taken in the past 6 months. Please complete the form below. Check your medicine cabinet and your medical records for drugs. Think back about the health problems you have had and the medicines you took for them.
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Name of drug, vitamin, or herbal substance used |
Dose |
# of pills |
Taken for how long? |
Taken for what problem? |
Still taking? |
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Yes |
No |
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SLEEP PROBLEMS CHECKLIST
What problem causes you to seek our help?________________________________________
__________________________________________________________________________
How does this problem affect your life?__________________________________________________________________________
__________________________________________________________________________
CHECK the boxes below for each problem you CURRENTLY HAVE:
| ð Loud snoring
ð Frequent awakenings at night
ð Choking for breath at night
ð Gasping during sleep
ð I’ve been told that I stop breathing when asleep
ð Restless sleep
ð Awaken un-refreshed
ð Crawling feelings in legs when trying to sleep
ð Leg-kicking during sleep
ð Leg cramps in sleep
ð Trouble falling asleep at night
ð Trouble staying asleep at night
ð Racing thoughts when trying to sleep
ð Increased muscle tension when trying to sleep
ð Fear of being unable to sleep
ð Fear of being unable to fall back to sleep after awakening at night
ð Laying in bed worrying when trying to sleep
ð Waking too early in the morning
ð Sleep talking
ð Sweating a lot at night
ð Waking up with heartburn
ð Waking up with reflux
ð Waking up to urinate |
ð Nightmares
ð Teeth grinding during sleep
ð Morning headaches
ð Morning dry mouth
ð Sleepwalking
ð Sleep terrors
ð Tongue biting in sleep
ð Bedwetting
ð Acting out dreams
ð Feeling paralyzed when falling asleep or waking up
ð Dreamlike images when falling asleep or waking up
ð Sudden weakness when laughing
ð Sudden weakness when afraid
ð Uncontrollable daytime sleep attacks
ð Falling asleep unexpectedly
ð Falling asleep at work
ð Falling asleep at school
ð Falling asleep while driving
ð Recent change in sleep schedule
ð Shift work interfering with sleep
ð I use sleeping pills to help me sleep
ð I use alcohol to help me sleep
ð Pain interfering with sleep
where is the pain? _______________ |