Pre Visit Questionnaire

This pre visit questionnaire is lengthy, but it is important that you complete it as best you can. Most of the questions include a dropdown box for easy selection or require just a yes or no answer.

Date
MM slash DD slash YYYY
Medical Record Number
General Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Weight
Height in Inches
BMI
How long do you have trouble sleeping?*
- Days
- Months
- Years
Have you been diagnosed with sleep apnea?*
- Yes
- No
If so, when/where?*
Have you used a CPAP machine for sleep apnea before?*
- Yes
- No
If so, last known pressure setting:*
Insomnia
Do you have trouble falling asleep (lay awake for half an hour or more)?*
- Yes
- No
Do you have trouble staying asleep once you fall asleep?*
- Yes
- No
Do you wake up earlier in the morning than you would like to?*
- Yes
- No
Do you feel like you don't get enough sleep?*
- Yes
- No
What is preventing you from a good night's sleep (choose all that apply):*
- Noise
- Pain
- Medication
- Shift work
- Worries
- Restless leg
- Cough
- Difficulty breathing
- Acid reflux
- Thoughts racing through your mind
Sleep habit/hygiene (choose all that apply):*
- Select All
- You have a clock in your bedroom
- You watch TV in your bedroom
- You take naps during the day
- You keep the lights on in the bedroom when you sleep
- You drink caffeine after dinner
- You are a shift worker
At what time do you usually go to bed on weekdays?*

: Hours

Minutes

AM/PM
At what time do you usually go to bed on weekends?*

: Hours

Minutes

AM/PM
At what time do you usually wake up on weekdays?*

: Hours

Minutes

AM/PM
At what time do you usually wake up on weekends?*

: Hours

Minutes

AM/PM
How many hours do you feel is your ideal amount of sleep per day?*
What is the average number of hours of sleep you had per day during the last week?*
Excessive Daytime Sleepiness/Hypersomnia
Do you feel sleepy and tired most of the day?*
- Yes
- No
Do you feel fatigued, exhausted, tired, or not up to par nearly every day?*
- Yes
- No
Do you feel that your sleep is not refreshing or restful?*
- Yes
- No
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep during the following situations? 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading*
- 0
- 1
- 2
- 3
Watching TV*
- 0
- 1
- 2
- 3
Sitting inactive in a public place (theater or meeting)*
- 0
- 1
- 2
- 3
Lying down to rest in the afternoon when circumstances permit*
- 0
- 1
- 2
- 3
Sitting and talking to someone*
- 0
- 1
- 2
- 3
Sitting in a car while stopped for a few minutes in traffic*
- 0
- 1
- 2
- 3
Your total score from answers to Epworth Sleepiness Scale questions above*
Restless Leg/Periodic Limb Movement Disorder
Do you experience a creeping, crawling, or aching feeling in your legs when you try to sleep?*
- Yes
- No
Do you have an urge to move your legs at night and can't keep still?*
- Yes
- No
Do you or have you been told that you kick or jerk during your sleep?*
- Yes
- No
Sleep Disordered Breathing
Do you snore or have you been told that you snore very loud at night?*
- Yes
- No
Is your snoring loud enough to bother your bed partner/other people in the household?*
- Yes
- No
Have you been told that you hold your breath while sleeping?*
- Yes
- No
Did you have a feeling of choking or suffocation during sleep?*
- Yes
- No
Do you wake yourself up snoring?*
- Yes
- No
Do you have dry mouth when you wake up?*
- Yes
- No
Do you have a headache when you wake up?*
- Yes
- No
Do you have periods of the day when you feel dazed and have trouble paying attention, remembering things, or staying awake?*
- Yes
- No
Narcolepsy
Do you have vivid dreams when you just fall asleep or just wake up?*
- Yes
- No
Do you have vivid dreams when you have daytime naps?*
- Yes
- No
Do you often feel that you are unable to move (paralyzed) when you are waking up?*
- Yes
- No
Do you get a sudden weakness (brief periods of paralysis or being unable to move) when you are laughing, angry, or in a situation of strong emotion?*
- Yes
- No
Parasomnias
Do you wake up at night with confusion and can't remember a thing in the morning?*
- Yes
- No
Do you sleepwalk?*
- Yes
- No
Do you wake up screaming loudly and crying?*
- Yes
- No
Do you experience head banging or body rocking during sleep?*
- Yes
- No
Do you experience arm, leg, or head jerks as you fall asleep?*
- Yes
- No
Do you talk in your sleep?*
- Yes
- No
Do you have painful cramps in the calf or in the foot?*
- Yes
- No
Do you have nightmares?*
- Yes
- No
Do you experience acting up dreams, talking, laughing, yelling, punching, screaming, leaping, or running out of bed?*
- Yes
- No
Do you grind or clench your teeth during sleep?*
- Yes
- No
Do you experience bedwetting?*
- Yes
- No
Do you have repeated movements of legs in the same pattern during sleep?*
- Yes
- No
Associated Medical Conditions
Do you have any of the following medical conditions (choose all that apply)?*
- High blood pressure (hypertension)
- Heart attack (myocardial infarction)
- Heart pain (angina)
- Heart failure (CHF)
- Stroke (CVA)
- Mini-stroke (TIA)
- Sinus congestion or obstruction
- Depression
- Asthma
- Emphysema (COPD)
- Hypoactive thyroid (hypothyroidism)
- Motor vehicle accident related to sleep condition
Consent*
I agree to allow the staff at LRH Sleep Disorders Center to contact me.
Email*
Enter Email Confirm Email
Phone*
Phone
This field is for validation purposes and should be left unchanged.

General Information

Insomnia

Excessive Daytime Sleepiness/Hypersomnia

Epworth Sleepiness Scale

Restless Leg/Periodic Limb Movement Disorder

Sleep Disordered Breathing

Narcolepsy

Parasomnias

Associated Medical Conditions