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Pre-Consult Questionnaire
Step
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Personal Information
Date Of Visit
*
MM slash DD slash YYYY
First Name
*
Last Name
*
Date of Birth
*
MM slash DD slash YYYY
The fields below are not necessary to fill out.
Study Date
MM slash DD slash YYYY
Height (ft, inches)
Weight (lbs)
Occupation
Neck Size (inches)
Waist Size (inches)
Referring Physician
1. My main sleep complaints are:
Difficulty Getting to Sleep
Yes
No
Sleep Talking
Yes
No
Difficulty Staying Asleep
Yes
No
Number of Awakenings From Sleep
How Long it Usually Takes to get Back to Sleep
Sleep Walking
Yes
No
Snoring
Yes
No
Acting Out Violent Dreams
Yes
No
Stop Breathing
Yes
No
Kicking During Sleep
Yes
No
Gasping
Yes
No
Restless Legs
Yes
No
Teeth Grinding
Yes
No
Night Sweats
Yes
No
Nightmares
Yes
No
Palpitations (Heart Racing)
Yes
No
Washroom Breaks
Yes
No
Number of Washroom Breaks
Narcolepsy Symptoms (Sleep Paralysis, Hallucinations, Cataplexy, etc)
Yes
No
Unknown
Uncontrolled Sleep Attacks
Yes
No
Sleep Paralysis
Yes
No
Cataplexy
Yes
No
Hallucinations
Yes
No
Automatism
Yes
No
Additional Notes
2. My main daytime complaints are:
Awaken Un-refreshed, Tired or Sleepy
Yes
No
Low Energy
Yes
No
Morning Headaches
Yes
No
Irritability
Yes
No
Daytime Fatigue
Yes
No
Depression
Yes
No
Daytime Sleepiness
Yes
No
Declining Memory
Yes
No
Poor Concentration
Yes
No
Daytime Naps
Yes
No
How long are your naps?
Do you use CPAP Therapy for Sleep Apnea?
Yes
No
Do you use medications for Insomnia?
Yes
No
If possible, please name the medications
Roughly how many years/months have you had these problems?
Additional Notes
3. Driving History
Do you drive?
Yes
No
Do you fall asleep while driving?
Yes
No
Sometimes
Always
Have you ever had an at fault motor vehicle collision?
Yes
No
Additional Notes
4. Sleep Hygiene
Shift Work
Do you work on a shift?
Yes
No
Shift Start Time
Shift End Time
Days per Week
Bed Routine
How quickly do you fall asleep?
Less than 5 minutes
Between 5 to 30 minutes
Between 30 to 60 minutes
Longer than an hour
Usual Bed Time
:
Hours
Minutes
AM
PM
AM/PM
Usual Wake Up Time
:
Hours
Minutes
AM
PM
AM/PM
Did you nap today?
Yes
No
How long did you nap for today?
Caffeine/Tea Use
Do you drink tea or drinks with caffeine?
Yes
No
How many cups per day?
Exercise Routine
Do you have an exercise routine?
Yes
No
Hours per day
Days per week
List of exercises:
Smoking
(cigarettes, cigars, pipes, etc)
Yes
No
How many per day/week?
Alcohol
(beer, wine, liquor, etc)
Yes
No
How many drinks per day/week?
Recreational Substances
(marijuana, cocaine, etc)
Yes
No
Occaionsally
Regularly
How many?
5. Medical History
Please select all that apply to you.
[[Heart Disease]]
[[Thyroid Disease]]
[[Musculo-skeletal Pain]]
[[High Blood Pressure]]
[[Depression]]
[[Obstructive Sleep Apnea]]
[[Chronic Bronchitis]]
[[Panic Attacks]]
[[Restless Leg Syndrome]]
[[Asthma]]
[[Epilepsy]]
[[Narcolepsy]]
[[Stroke]]
[[Allergies]]
[[Diabetes]]
[[History of Skin Rashes]]
Site of Musculo-skeletal Pain
Other(s):
6. Medications
Please list all medications and doses if known, separated by a comma.
7. Family History
Please list any known medical conditions in your family history.
Father
Mother
Brother
Sister
Adult Children
Others:
8. Epworth Sleepiness Scale
What are the chances of you falling asleep in these situations?
(This section describes the possibility of unplanned sleep, not just feeling tired, on a scale of 0 to 3)
Sitting and Reading
0 - Never
1 - Slight
2 - Moderate
3 - High
Watching TV
0 - Never
1 - Slight
2 - Moderate
3 - High
Sitting Inactively in a Public Place (in a theatre, meeting, etc)
0 - Never
1 - Slight
2 - Moderate
3 - High
As a Passenger in a Car for an Hour Without a Break
0 - Never
1 - Slight
2 - Moderate
3 - High
Lying Down to Rest in the Afternoon
0 - Never
1 - Slight
2 - Moderate
3 - High
Sitting and Talking to Someone
0 - Never
1 - Slight
2 - Moderate
3 - High
Sitting Quietly After Eating Lunch (Without Alcohol)
0 - Never
1 - Slight
2 - Moderate
3 - High
In a Car, While Stopped for a Few Minutes in Traffic
0 - Never
1 - Slight
2 - Moderate
3 - High
9. Stanford Sleepiness Scale
Select only one statement that best describes how you feel right now.
1. Feel active and vital, alert, wide awake
2. Functioning at high level but not at peak, able to concentrate
3. Relaxed, awake and responsive but not at full alertness
4. A little foggy, not at peak, let down
5. Fogginess, beginning to lose interest in remaining awake
6. Sleepiness, prefer to lie down, fighting sleep
7. Almost in reverie, sleep onset soon, lost struggle to remain awake
Authorization
*
I confirm that the information provided is the most accurate to the best of knowledge.
Phone
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