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Name ________________________________________________________________________

Age _____ Sex _____ Height _____Weight ______ Telephone: (_____) - ______- _________

Your address __________________________________________________________________

E-mail address _________________________________________________________________

Family Doctor _________________________________________________________________

Family doctor's address _________________________________________________________

A. What complaints do you have related to sleep?

1. ___ excessive sleepiness/ fatigue ___ fall asleep at inappropriate times

2. Awakenings with:

____ snores/ snorts/ short of breath

____ chest pain, palpitations

____ throat "closed off"

____ throat dry/painful

____ headache

____ leg jerks

____ sour/bitter taste, heartburn

____ panic without nightmare recall

3. Insomnia:

____ lie wide awake initially, can't "turn off thoughts"

____ arouse repeatedly and/or sleep is light/ fragmented

____ lie wide awake initially because my legs feel "antsy"/ restless

____ wake up too early/ can't return to sleep

B. If others have had opportunities to observe your sleep and alertness, do they complain that you:

___ snore badly

___ fall asleep at inappropriate times

___ stop breathing

___ fall asleep driving

___ thrash in sleep

___ have episodes of staring/"going blank"

___ convulse in sleep

___ walk or run in sleep

___ have leg/body jerks in sleep

___ act out dreaming

___ scream out in sleep

___ choke in sleep

C. Have you experienced any of the following?:

___ falling asleep at the wheel

___ confusion/ trouble with memory

___ sleep related highway accidents or "near-misses"

___ biting of tongue/ inside of cheek in sleep

___ having to pull over often while driving to nap

___ muscle aching/ fibromyalgia

___ frequent driving while on "automatic pilot"

___ bedwetting after age 6 years

___ dreaming in brief naps

___ episodes of impaired consciousness, staring or feelings of unreality

___ "seeing/hearing things" when drowsy

___ abnormal tastes, unrelieved by rinsing mouth, and always identical

___ complete paralysis when first awakening or dozing off

___ abnormal odors, always identical, not perceived by others

___ sudden loss of strength/ muscle control provoked by strong emotions (i.e.: laughter, anger)

___ visual distortions not due to eye problems/ eyeglasses (objects appear distorted in shape, size or appearance)

D. Have you had any of the following health problems?:

___ heart problems (coronary disease, heart failure, abnormal heart rhythm]

___ high blood pressure ___ stroke ___ chronic lung disease (ex: asthma, emphysema, 'COPD')___ epilepsy/ seizures

Please make any other comments or related observations on back, then share this with your doctor. Or you may forward it for a free review to the:

Accredited by the American Academy of Sleep Medicine.

Robert W. Clark, M.D., Medical Director
1430 South High Street
Columbus OH 43207

Tel: [614] 443-7800

Fax: [614] 443-6960


Copyright 2006 Robert W. Clark M.D. Inc