Center For Disorders of Sleep Fatigue
A Subsidiary of Spartanburg Neurological Services, P.A.
Center For Disorders of Sleep Fatigue
SLEEP HISTORY
(TO BE COMPLETED BY PATIENT)
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Name:
Social Security number: - -
Date: / /

Spouse or emergency contact(s):


Send copy of results to (e.g., family physician, internist):


CHIEF COMPLAINT

Check any of the following that apply:

Loud snoring Breathing or snoring stops for brief periods in my sleep Awaken gasping for breath Do not feel restored with I awaken Become sleepy during the day while (check all that apply): sitting riding driving talking eating standing Difficulty falling asleep Difficulty remaining asleep Awaken too early

My MAIN sleep problem has bothered me: 1 to 2 years longer than 2 years several months to 12 months within the last 3 months within the last month

SLEEP TREATMENT

I was previously diagnosed with:

Sleep apnea

	When?
	Where?

My prior treatment included:

CPAP or BiPAP or Bilevel	Uvulopalatopharyngoplasty
Indicate treatment level (if known):	Laser or other procedure on uvula
Oral appliance	Mandibular surgery
Sinus, deviated septum, or turbinate reduction	Tonsils and/or adenoidectomy

Restless legs syndrome
When? Where? Treatment:

Periodic limb movements
When? Where? Treatment:

Narcolepsy
When? Where? Treatment:

Insomnia
When? Where? Treatment:

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SYMPTOMS DURING SLEEP

Indicate ON AVERAGE how often you experience the following symptoms, especially when sleeping or trying to sleep:

Times per week

None 1-3 4-6 Daily Symptom My mind races with many thoughts when I try to fall asleep I often worry whether or not I will be able to fall asleep Fatigue Anxiety Memory impairment Inability to concentrate Irritability Depression Awaken with a dry mouth Morning headaches Pain which delays or prevents my sleep Pain which awakens me from sleep Vivid or lifelike visions (people in room, etc.) as you fall asleep or wake up Inability to move as you are trying to go to sleep or wake up Sudden weakness or feel your body go limp when you are angry or excited Irresistible urge to move legs or arms Inability to move as you are trying to go to sleep or wake up Legs or arms jerking during sleep Sleep talking Sleep walking Nightmares Fall out of bed Heartburn, sour belches, regurgitation, or indigestion which disrupts sleep Bed wetting Frequent urination disrupting sleep Teeth grinding Wheezing or cough disrupting sleep Sinus trouble, nasal congestion or post-nasal drip interfering with sleep Shortness of breath disrupting sleep

SLEEP HABITS

Please asnwer the following questions as accurately as possible. Indicate AM and PM. If your work and/or sleep schedule changes during the week, then indicate your schedule using the "shift work" column (if your schedule does not change, simply check the "N/A" box).

Activity Usual schedule Weekends Shift work ( N/A) Lights out 121234567891011 : 00153045 AMPM 121234567891011 : 00153045 AMPM 121234567891011 : 00153045 AMPM I usually fall asleep in minuteshours minuteshours minuteshours How many times do you awaken each night? time(s) time(s) time(s) Number of times you have difficulty returning to sleep time(s) time(s) time(s) The total time I spend awake in bed minuteshours minuteshours minuteshours I usually awake from sleep at 121234567891011 : 00153045 AMPM 121234567891011 : 00153045 AMPM 121234567891011 : 00153045 AMPM What time do you usually get out of bed from sleep? 121234567891011 : 00153045 AMPM 121234567891011 : 00153045 AMPM 121234567891011 : 00153045 AMPM How many hours of sleep do you get on average? hours hours hours Do you take naps and, if so, for how long? minuteshours or N/A minuteshours or N/A minuteshours or N/A Begin work time 121234567891011 : 00153045 AMPM or N/A 121234567891011 : 00153045 AMPM or N/A 121234567891011 : 00153045 AMPM or N/A End work time 121234567891011 : 00153045 AMPM or N/A 121234567891011 : 00153045 AMPM or N/A 121234567891011 : 00153045 AMPM or N/A

If you do rotating shift work, or have other work schedule changes and need more space to describe, please do so here:


MEDICAL HISTORY

Please check if you have had any of the following:

Heart disease	Diabetes	Depression	High blood pressure
List type (e.g., CHF):	Asthma/Emphysema	Reflux	Thyroid condition
Fibromyalgia	Anxiety	Seizures	Parkinson's disease
Stroke	Head injury or brain surgery

Pain which disrupts sleep. The typical location(s) for this pain is/are:

Headaches Neck Back Chest Limb (arm[s] or leg[s]) Abdominal Pelvic Joint (arthritis)

Other medical problems which may affect sleep (please list):


WEIGHT

What is your weight in pounds?
1 year ago 5 years ago

What is your collar size?
1 year ago 5 years ago

MEDICATION

Do you take anything to help you sleep? YesNo
If so, what? How often?

List current medications and dosages, including both perscriptions and over-the-counter medications:


Are you on supplemental oxygen? YesNo
If yes, how much (in liters per minute)?

SOCIAL HISTORY

Do you smoke? YesNo Did you previously smoke? YesNo
How many years of smoking? How much per day?

Do you drink alcohol? YesNo
How much? drinks per dayweekmonth

How much caffeinated coffee, tea, or cola do you drink daily?

What do you usually do at work?


ENVIRONMENT

Is your bedroom loudquiet and lightdark?
Is your mattress softhardjust right?
Do you go to sleep with the television on? YesNo
Is your sleep disturbed because of your bed partner or others in your household (children or pets)? YesNo

FAMILY HISTORY (Please check all that apply)

Is there a family history of: Apnea Snoring Narcolepsy Insomnia Restless Legs Syndrome Other sleep disturbances Mother Father Sister(s) Brother(s) Grandparent(s)

Epworth Sleepiness Scale

How likely are you to doze off of fall asleep in the following situation, 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 do choose the most appropriate number for each situation.

0 = would never dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation Chance of Dozing Sitting and reading 0123 Watching TV 0123 Sitting, inactive, in a public place (e.g., a theater or a meeting) 0123 As a passenger in a car for an hour without a break 0123 Lying down to rest in the afternoon when circumstances permit 0123 Sitting and talking with someone 0123 Sitting quietly after a lunch without alcohol 0123 In a car, while stopped for a few minutes in traffic 0123

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