SLEEP SCREENING QUESTIONNAIRE



SLEEP SCREENING QUESTIONNAIREThis questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your time and answer each question as completely and honestly as possible. Please sign each page.Patient InformationTODAY’S DATE: ______________________________ MR. _____ MS _____ MISS _____ MRS. _____ DR. NAME: ___________________________________________________________________________________________________________________________FIRSTMIDDLE INITIALLASTAGE: _______________BIRTH DATE: ________________________________ MALE _____ FEMALEADDRESS: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CITYSTATEZIPEMAILEMPLOYED BY: __________________________________________________________________________________________________________________HOME PHONE: __________________________ WORK PHONE: __________________________ CELL PHONE: ___________________________PHYSICIAN: ______________________________________________________________________________________________________________________DENTIST: ________________________________________________________________________________________________________________________Please list other health care practitioners seen in the last 9 months: __________________________________________________________________________________________________________________________________________________________________________________________HEIGHT:________ Feet _________ InchesWEIGHT: __________ PoundsREFERRED BY: __________________________________________________________________________________________________________________WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT?Please number the complaints with #1 being the most important._____ Frequent heavy snoring_____ Morning hoarseness_____ Which affects the sleep of others_____ Morning headaches_____ Significant daytime drowsiness_____ Swelling in ankles or feet_____ I have been told that “I stop breathing” when sleeping_____ Nocturnal teeth grinding_____ Difficulty falling asleep_____ Jaw pain_____ Gasping when waking up_____ Facial pain_____ Nighttime choking spells_____ Jaw clicking_____ Feeling unrefreshed in the morningOther: ____________________________________________Other: _____________________________________________Patient Signature: ________________________________________________________________________________Date _______________________ CPAP INTOLERANCE(Continuous Positive Airway Pressure device)If you have attempted treatment with a CPAP device, but could not tolerate it please fill in this section:I could not tolerate the CPAP device due to:_____ mask leaks_____ I was unable to get the mask to fit properly_____ discomfort caused by the straps and headgear_____ disturbed or interrupted sleep caused by the presence of the device_____ noise from the device disturbing my sleep and/or bed partner’s sleep_____ CPAP restricted movements during sleep_____ CPAP does not seem to be effective_____ pressure on the upper lip causing tooth related problems_____ a latex allergy_____ claustrophobic associations_____ an unconscious need to remove the CPAP apparatus at nightOther:________________________________________________________________________________________________________OTHER THERAPY ATTEMPTSWhat other therapies have you had for breathing disorders?(weight –loss attempts, smoking cessation for at least one month, surgeries, etc.)Patient Signature: ________________________________________________________________________________Date _______________________List any medications which have caused an allergic reaction:Y _____ N_____ AntibioticsY _____ N_____ MetalsOther allergies:Y _____ N_____ AspirinY _____ N_____ Penicillin____________________________________________________Y _____ N_____ BarbituratesY _____ N_____ Plastic____________________________________________________Y _____ N_____ CodeineY _____ N_____ Sedatives____________________________________________________Y _____ N_____ IodineY _____ N_____ Sleeping Pills____________________________________________________Y _____ N_____ LatexY _____ N_____ Sulfa drugs____________________________________________________Y _____ N_____ Local anestheticsList any medications you are currently taking:Y _____ N_____ AntacidsY _____ N_____ CodeineY _____ N_____ Pain medicationY _____ N_____ AntibioticsY _____ N_____ CortisoneY _____ N_____ Sleeping pillsY _____ N_____ AnticoagulantsY _____ N_____ Diet pillsY _____ N_____ Sulfa drugsY _____ N_____ AntidepressantsY _____ N_____ Heart MedicationY _____ N_____ TranquilizersY _____ N_____ Anti-inflammatoryY _____ N_____ High blood pressure medication drugs (non-steroid)Y _____ N_____ InsulinOther current medications: ____________________Y _____ N_____ BarbituratesY _____ N_____ Muscle relaxants_______________________________________________________Y _____ N_____ Blood thinnersY _____ N_____ Nerve Pills_______________________________________________________Medical HistoryY _____ N_____ AnemiaY _____ N_____ Heart pacemakerY _____ N_____ OsteoarthritisY _____ N_____ ArteriosclerosisY _____ N_____ Heart valve replacementY _____ N_____ OsteoporosisY _____ N_____ AsthmaY _____ N_____ Heartburn or a sour taste Y _____ N_____ Poor circulationY _____ N_____ Autoimmune disorders in the mouth at nightY _____ N_____ Prior orthodonticsY _____ N_____ Bleeding easilyY _____ N_____ HepatitisY _____ N_____ Recent excessiveY _____ N_____ Chronic sinus problemsY _____ N_____ High blood pressure weight gainY _____ N_____ Chronic fatigueY _____ N_____ Immune system disorderY _____ N_____ Rheumatic FeverY _____ N_____ Congestive heart failureY _____ N_____ Injury toY _____ N_____ Shortness of breathY _____ N_____ Current pregnancy_____ Face _____ NeckY _____ N_____ Swollen, stiff or Y _____ N_____ Diabetes_____ Head _____ Mouth _____ Teeth painful jointsY _____ N_____ Difficulty concentratingY _____ N_____ InsomniaY _____ N_____ Thyroid problemsY _____ N_____ DizzinessY _____ N_____ Irregular heart beatY _____ N_____ TonsillectomyY _____ N_____ EmphysemaY _____ N_____ Jaw joint surgeryY _____ N_____ Wisdom teeth extractionY _____ N_____ EpilepsyY _____ N_____ Low blood pressureOther medical history:Y _____ N_____ FibromyalgiaY _____ N_____ Memory loss___________________________________________________Y _____ N_____ Frequent sore throatsY _____ N_____ Migraines___________________________________________________Y _____ N_____ GERDY _____ N_____ Morning dry mouth____________________________________________________Y _____ N_____ Hay feverY _____ N_____ Muscle spasms or cramps____________________________________________________Y _____ N_____ Heart disorderY _____ N_____ Needing extra pillows toY _____ N_____ Heart murmur help breathing at nightY _____ N_____ Heart pounding orY _____ N_____ Nighttime sweating beating irregularly during the nightPatient Signature: ________________________________________________________________________________Date _______________________Family History1. Have any members of your family (blood kin) had:Yes _____ No_____ Heart diseaseYes _____ No_____ High blood pressureYes _____ No_____ Diabetes2. Have any immediate family members been diagnosed or treated for a sleep disorder?Yes _____ No_____Social HistoryAlcohol consumption: How often do you consume alcohol within 2-3 hours of bedtime?_____ Never _____Once a week _____ Several days a week _____Daily _____ OccasionallySedative consumption: How often do you take sedatives within 2-3 hours of bedtime?_____ Never _____Once a week _____ Several days a week _____Daily _____ OccasionallyCaffeine consumption: How often do you consume caffeine within 2-3 hours of bedtime?_____ Never _____Once a week _____ Several days a week _____Daily _____ OccasionallyDo you smoke? _____ Yes _____ NoDo you use chewing tobacco? _____ Yes _____ NoI authorize the release of a full report of examination findings, diagnosis, treatment programs, etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all fees for treatment regardless or insurance coverage.Patient Signature: ________________________________________________________________________________Date _______________________Berlin Questionnaire Sleep EvaluationCATEGORY 1CATEGORY 2Complete the following:Height __________ age __________Weight __________male/female ____________Do you snore? _____ Yes_____ No_____ Don’t knowYour snoring is?_____ slightly louder than breathing_____ as loud as talking _____ louder than talking _____ very loud. Can be heard in adjacent roomsHow often do you snore? _____ nearly every day _____ 3-4 times a week_____ 1-2 times a week_____ 1-2 times a month_____ never or nearly neverHas your snoring ever bothered other people? _____ Yes _____ NoHas anyone noticed that you quit breathing during your sleep? _____ nearly every day _____ 3-4 times a week_____ 1-2 times a week _____ 1-2 times a month_____ never or nearly neverHow often do you feel tired or fatigued after your sleep? _____ nearly every day _____ 3-4 times a week_____ 1-2 times a week _____ 1-2 times a month_____ never or nearly neverDuring your wake time, do you feel tired, fatigued or not up to par? _____ nearly every day _____ 3-4 times a week _____ 1-2 times a week _____ 1-2 times a month _____ never or nearly neverHave you ever nodded off or fallen asleep while driving a vehicle? _____ Yes _____ No If yes, how often does it occur? _____ nearly every day _____ 3-4 times a week _____ 1-2 times a week _____ 1-2 times a month _____ never or nearly never CATEGORY 3Do you have high blood pressure? _____ Yes_____ No_____ Don’t know(For office use)Scoring Questions: Any answer within the box outline is a positive responseScoring categories:Category 1 is positive with 2 or more positive responses to questions 2-6 _____Category 2 is positive with 2 or more positive responses to questions 7-9_____Category 3 is positive with 1 positive responses and/or a BMI>30 _____ (BMI = Body Mass Index) Final Result:2 or more possible categories indicate a high likelihood of sleep disordered breathing.Patient Signature: ________________________________________________________________________________Date _______________________THE EPWORTH SLEEPINESS How likely are you to doze off or fall asleep in the following situations?√ Check one in each row:0No chanceof dozing1Slight chance of dozing2Moderate chanceof dozing3High chanceof dozingSitting and reading□□□□Watching TV□□□□Waiting inactive in a public place (i.e. a theater or a meeting)□□□□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 a lunch without alcohol□□□□In a car, while stopping for a few minutes in traffic□□□□Total Score: ___________ (add columns 0-3)FATIGUE SCALEDuring the past week:No<< 123456>>Yes7I felt fatigued and had less motivation□□□□□□□I felt fatigued and did not desire to exercise□□□□□□□I felt fatigued often□□□□□□□I felt fatigue that interfered with my physical functioning□□□□□□□I felt fatigued which caused me frequent problems□□□□□□□I felt fatigued which prevented sustained physical functioning□□□□□□□I felt fatigued and couldn’t carry out certain duties and responsibilities□□□□□□□Fatigue was among my three most disabling symptoms□□□□□□□Fatigue interfered with my work, family or social life□□□□□□□Total Score: ___________Patient Signature: ________________________________________________________________________________Date _______________________ ................
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