Sleep Health Update Sleep Health Update Patient first name(Required)Last name(Required)Email(Required) Enter Email Confirm Email Date of Birth(Required)Date(Required) MM slash DD slash YYYY Please write today’s main problem/concernWhat time do you usually go to bed?How long does it take you to fall asleep?Do you take any sleep aids? Yes No How often?Do you wake up at night? Yes No How many times?Please list reasons you wake up…What time do you usually wake up in the morning?Do you feel refreshed? Always Sometimes Never Are you sleepy during the day? Always Sometimes Never Do you doze off or take naps? Always Sometimes Never Do you fall asleep while driving? Always Sometimes Never Any motor vehicle accidents? Yes No Do you use a CPAP machine? Yes No Please answer the following if you use a CPAP machine:What type of mask do you use? Nasal mask Full face mask Nasal pillows Are you having problems with your CPAP mask? Yes No Do you have significant morning dry mouth? Yes No Which company supplies your CPAP equipment?How likely are you to doze off or fall asleep in the following situations? 0 = would never doze off — 1 = slight chance of dozing off — 2 = moderate chance of dozing off — 3 = high chance of dozing offSitting 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 9.7.2022EmailThis field is for validation purposes and should be left unchanged.