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SLEEP QUESTIONNAIRE II.
[To be completed by a family member or friend who
has observed the patient's sleep and alertness.]
 

Name _____________________________________________________________________________

Name of patient ____________________________________________________________________

Your relationship to the patient _______________________________________________________

Patient's telephone: (_____) - ______- _________ Your telephone: (_____) - ______- _________

Your address _______________________________________________________________________

Your E-mail address _________________________________________________________________

Patient's doctor ____________________________________________________________________

Patient's doctor's address ____________________________________________________________

TO THE OBSERVER: WE APPRECIATE YOUR INPUT! YOUR RESPONSES TO THE FOLLOWING
MAY HELP PROVIDE EXPLANATIONS FOR THE SLEEP PROBLEMS OF THOSE CLOSE TO YOU.
 

A. WHAT OPPORTUNITIES HAVE YOU HAD TO OBSERVE THE PERSON'S SLEEP?

___ Frequent: share bed or bedroom and sleep lightly.

___ Have had little or no opportunity to observe the person during sleep.


B. IF YOU NO LONGER CAN SLEEP IN THE SAME BED OR BEDROOM AS THE PERSON, WHY NOT?

___ The person snores loudly.

___ The person screams out or behaves frantically/ violently in sleep.

___ Own sleep problem.

___ The person kicks, flings arms or is too restless in sleep.


C. IF THE PERSON SNORES, WHICH OF THE FOLLOWING APPLY?

___ frequent snoring

___ snoring is irregular with gasps

___ loud snoring

___ struggling to breathe

___ long pauses in breathing occur

___ turns blue/ dusky

___ have prodded person to stimulate breathing

___ the breathing problem is frightening!



D. WHAT OTHER EVENTS DURING SLEEP HAVE YOU NOTICED?

___ sitting or standing up in sleep

___ screaming out

___ repetitive body jerks

___ acting out of dreams

___ heavy sweating

___ biting tongue/inside of mouth

___ sleepwalking

___ generalized shaking

___ choking/gagging/vomiting

___ running or frantic/violent behavior

___ eyes rolling up

___ bedwetting



E. WHICH OF THE FOLLOWING EVENTS HAVE YOU NOTED DURING WAKEFULNESS?

___ seems too sleepy

___ personality change/ irritability

___ muscular weakness or collapse with emotions

___ falls asleep at inappropriate times

___ confusion or worsening memory

___ seizures or convulsions

___ falls asleep when driving/ talking

___ episodes of staring/"going blank"

___ episodes of panic or intense anxiety



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



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: [614] 443-7800

Fax: [614] 443-6960

e-mail: flamenco@netexp.net

The results of this free review will then be shared with the patient and/or the patient's doctor.

Thank you for helping us help the patient!

 © Copyright 2006 Robert W. Clark M.D. Inc.