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.

  • MM slash DD slash YYYY
  • General Information

  • MM slash DD slash YYYY
  • Insomnia

  • :
  • :
  • :
  • :
  • Excessive Daytime Sleepiness/Hypersomnia

  • 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
  • Restless Leg/Periodic Limb Movement Disorder

  • Sleep Disordered Breathing

  • Narcolepsy

  • Parasomnias

  • Associated Medical Conditions

  • This field is for validation purposes and should be left unchanged.