Name:
Date:
Email:
Phone:
What time do you usually get into bed on weekdays?
How long after getting into bed do you decide to go to sleep?
On average, how long (in minutes) does it take you to fall asleep?
How many hours of actual sleep do you estimate you obtain overnight?
Do you wake up to an alarm? YesNo
What is your preferred sleep position?
Do you engage with electronic devices at bedtime? YesNo
Do you experience mind racing at bedtime? YesNo
what are some thought themes your mind focuses on?
Are you on any medications or other substances to aid with sleep? YesNo
Please list medications and doses here is it beneficial? YesNo
How many minutes/hours before bedtime do you use your medication?
Do you experience an irresistible urge to move your legs before you fall asleep? YesNo
Do you have any joint/body pain that affects you trying to fall asleep? YesNo
Do you feel paralyzed when trying to fall asleep? YesNo
Do you experience visual or auditory hallucinations as you are trying to fall asleep? YesNo
Do you know that you snore or have you been told that you do? YesNo
Have you awoken from sleep choking/gasping for air or feeling short of breath? YesNo
Have you been told that you stop breathing while asleep? YesNo
How many times do you wake up in the middle of the night?
Any known triggers for your nocturnal awakenings?
Do you have trouble returning to sleep if you wake up in the middle of the night? YesNo
How long does it take you to return to sleep on average?
Have you been told that you exhibit repetitive leg kicks/twitches during sleep? YesNo
Do you grind or clench your teeth while asleep? YesNo
Do you use a mouthguard?
Do you sleepwalk? YesNo
Do you experience frequent night terrors or nightmares? YesNo
Have you been told that you seem to act out your dreams? YesNo
Have you inadvertently hit your bedtime partner or injured yourself while asleep? YesNo
Do you feel well rested when you wake up?
YesNo
Do you wake up with a headache?
Do you wake up with a dry mouth or sore throat?
Do you wake up with your heart racing or pounding?
Have you felt like you couldn't move upon awakening?
Have you experienced visual or auditory hallucinations upon awakening?
Do you experience fatigue or sleepiness during the daytime?
Have you drifted off to sleep when engaged in non-stimulating activities like watching TV?
How often does this happen in a week?
How many days in a week do you take a daytime nap?
How long are your naps?
Are these naps refreshing?
Do you experience lucid dreams during daytime naps?
Do you experience any memory or concentration difficulties?
Have you dozed off or felt sleepy while driving?
When was the last time this occurred?
Have you been involved in a close call or accident due to drowsy driving?
Have there been times when you experienced weakness in several muscles/joints in your body when you are laughing, angry, scared or startled?
how often does this happen?
Do you smoke or vape?
On a typical day, when is your last smoke or vape session?
Do you smoke during your nocturnal awakenings?
Do you consume caffeinated drinks? (coffee, soda, energy drinks etc).
How much in a day?
When is your last caffeine intake on a typical day?
How often do you consume alcohol in a week?
What time is your last alcohol intake on a typical day?
Insomnia?
Please list any medications and/or treatments:
Sleep Apnea?
With what treatment?
CPAPDental ApplianceHypoglossal nerve stimulation therapy (Inspire)Neuromuscular electrical stimulation (exciteOSA)Positional therapySurgery
Other Sleep Disorder?
Please check any that apply
Restless Legs SyndromeNarcolepsyPeriodic Limb Movement DisorderParasomnia (sleepwalking/sleep terrors)
Reason for sleep study. (required) Please click all that apply
SnoringWaking up gasping for airStopping breathing during sleepDifficulty falling asleepDifficulty staying asleepMorning headachesNon-restorative sleepFatigueExcessive daytime sleepinessActing out dreamsSleepwalkingSleep eatingNightmaresSleep paralysisRestless legsDrowsy driving
Other symptoms
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