Patient Sleep Questionnaire 

Patient Sleep Questionnaire

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MM slash DD slash YYYY
This questionnaire is used for all of Dr. Simmons programs: please choose the clinic location you wish the response to be directed to (mandatory):*

1. Have you had a sleep study before?
If yes, are you currently on CPAP/BiPAP?
If you are currently on CPAP or BiPAP then your responses below should be in the context of how you are while using your treatment.
3. Do you have difficulty falling asleep?
If yes, do you plan your next day while lying in bed trying to fall asleep?
If yes, do you have racing thoughts going through your mind while trying to fall asleep?
4. Do you have difficulty staying asleep?
5. Do you take medications to fall or stay asleep?
6. Do you feel refreshed when you awaken to start your day?
7. Do you experience an unsettled, restless sensation in your legs while lying in bed?
If yes, how often?
If yes, does movement of your legs calm down the restless sensations at least briefly?
8. Have you been told that you kick or twitch your legs while you are asleep?
9. Do you snore at night?
If yes, how would you rate the severity?
10. Have others told you that you have pauses in breathing or that you make gasping sounds when sleeping?
If yes, how frequent are the pauses or gasping?
11. Does your bed partner frequently sleep in another room because of how you sleep?
12. Do you frequently wake up with a: (Check those that apply to you)
13. Do you have unusual behaviors in your sleep?
If yes, what part of the night do these typically occur?
14. Do you have difficulty maintaining concentration during the day?
15. Are you sleepy during the day?
16. Do you take naps often?
Do you usually dream during these naps?

What is your daily consumption of:

18. Do you occasionally awaken feeling paralyzed?
19. Do you experience sudden loss of strength in your legs or arms during the day?
If yes, are these brought on by a sudden frightening event or laughter?

Rank how likely it would be for you to become drowsy (like you’re going to fall asleep, rather than just feeling tired) during the day in the following situations:

0 = never become drowsy, 1 = rarely become drowsy, 2 = frequently become drowsy, 3 = always become drowsy

Sitting and Reading:
Watching TV:
Sitting inactive in a public place (e.g. theater):
As a passenger in a car for an hour without a break:
Lying down to rest in the afternoon when circumstances permit:
Sitting and talking to someone:
Sitting quietly after lunch without alcohol:
In a car while stopped for a few minutes in the traffic:

Have you had a sleep study before?
Have you had surgery for sleep apnea before?
Do you need assistance at night by other people?
Do you have COPD?
Are you on Oxygen at night?

Referral Source:

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