Sleep Health Questionnaire Sleep Health Questionnaire Patient first name(Required)Last name(Required)Email(Required) Enter Email Confirm Email Date of Birth(Required)Date(Required) MM slash DD slash YYYY Present Height(Required)State in feet (ft), and inches (in)Present Weight(Required)State in pounds (lbs)Please state, in your own words, the reason for a sleep evaluation.Have you had previous sleep evaluation? Yes No When and what were the results?Please check any of the following that may affect your sleep—— Snoring Choking sensation Shortness of breath —— Morning dry mouth Morning headache Heart racing —— Chest pain Sweating at night —— Difficulty falling asleep Many awakenings —— Worried about not sleeping Anxiety/racing thoughts —— Waking up before alarm Sleep better when away from home —— Urge to move legs Relief with movement Creepy crawley feeling —— Leg/foot cramps Pain or discomfort —— Muscle tension Symptoms worse at night —— Nightmares/ bad dreams Wake up in a panic Wake up screaming Wake up with violence —— Wake up confused Acting out in dreams Sleep walking Sleep talking —— Eating at night Wet the bed Shaking/convulsive movements Tongue biting —— Feeling unable to move Daytime sleep attacks Bed partner/moving —— Noise Caring for Children Room temperature —— Sounds/images when falling asleep or waking up Your body becomes weak or limp with strong emotions —— Other If "other", please describe:Have you had a motor vehicle crash (or near-miss) due to daytime sleepiness? Yes No If so, how often and/or when did it occur?How much weight have you gained or lost in the past 1 year?How often do you exercise? (times/week)What time of day?Activities you do in the bedroomIf you watch TV, how long per day and night?If you use a computer, how long per day and night?If you use a phone or tablet, how long per day and night?If you read, how long per day and night?If you work or study, how long per day and night?Sleep ScheduleWhat time do you go to bed?Do you take any sleep aids?How long does it take you to fall asleep?How many times do you wake up during the night?What time do you wake up in the mornings?How often do you take naps?What are your work hours?What days do you work?HabitsIf you drink caffeinated tea, how long per day and night?If you drink caffeinated coffee, how long per day and night?If you drink caffeinated soda, how long per day and night?What time is your last drink of the day?If you drink wine, how long per day and night?If you drink beer, how long per day and night?If you drink mixed drinks, how long per day and night?What time is your last drink of the day?If you smoke cigarettes, how long per day and night?If you smoke cigars, how long per day and night?If you chew tobacco, how long per day and night?What time is your last tobacco use?How long have you use tobacco?Do you have a history of non-prescription drug use? Yes No If so, please list what you have used:Likelihood of falling asleep 0 = would never doze off — 1 = slight chance — 2 = moderate chance — 3 = high chanceSitting and reading 0 1 2 3 Watching TV 0 1 2 3 Sitting quietly in a public place (i.e. theatre or meeting) 0 1 2 3 As a passenger in a car for an hour without a break 0 1 2 3 Lying down to rest in the afternoon when able to 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch without alcohol 0 1 2 3 In a car, while stopped for a few minutes 0 1 2 3 Rev 9.7.2022NameThis field is for validation purposes and should be left unchanged.