SLEEP QUESTIONNAIRE I.
[TO BE COMPLETED BY THE PATIENT.]
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
____ leg jerks
____ sour/bitter taste, heartburn
____ panic without nightmare recall
____ 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
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:
COLUMBUS COMMUNITY HEALTH
REGIONAL SLEEP DISORDERS CENTER
Accredited by the American Academy of Sleep Medicine.
Robert W. Clark, M.D., Medical Director
1430 South High Street
Columbus OH 43207
Tel:  443-7800
Fax:  443-6960
Copyright 2006 Robert W. Clark M.D. Inc.