Charlotte Eye Ear Nose & Throat Associates, P



Sleep QuestionnaireCharlotte Eye Ear Nose & Throat Associates, P.A.South Park Office/ Belmont OfficeSP Phone (704) 295-3000/Belmont (704) 295-3700Name:______________________________Date:___________Account #:_________THE MODIFIED EPWORTH SLEEPINESS SCALEHow likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these activities recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation:0=would never doze1= slight chance of dozing2=moderate chance of dozing3=high chance of dozingSITUATIONCHANCE OF DOZINGSitting and reading_______Watching TV_______Sitting, inactive in a public place (theater, meeting, etc)_______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 stopped for a few minutes in the traffic_______Total points_______Please describe your sleep problem:________________________________________________________________________________________________________________________________________________What time do you usually go to bed? __________________________________________What time do you usually get up? ____________________________________________What is your work schedule? ________________________________________________How long does it take you to fall asleep? ______________________________________What do you usually do when you awaken during the night?________________________________________________________________________Do you have any unusual behavior during sleep of which you or others are aware?___yes ___noIf yes, please describe: ________________________________________________________________________Do you take naps?___yes___noWhat times? _________________________ For how long? _________________Are your naps refreshing?___yes ___noDO YOU:YESNO Remember your dreams__________Have vivid dream like scenesupon awakening or going to sleep__________Feel unable to move when waking or falling asleep __________Experience loss of muscle tone when extremely emotional__________Snore__________Sleep with your mouth open _____ _____Wake with dry mouth__________Have breathing problems__________Awaken at night with heartburn, _____ _____Belching or cough/wheezing__________Sweat excessively at night__________Awaken with a headache__________Are awakened by pain at night__________Kick during the night__________Experience crawling and aching feelings in your legs__________Experience any kind of leg pain during the night__________Grind teeth during sleep or jaw pain__________Have nightmares__________Have thoughts racing through your mind__________Feel sad or depressed__________Take something to help you sleep__________For each of the beverages below, write in the average number you drink per day.Caffeinated coffee _______ cups per dayTea ______ cups/glasses per daySoft drinks _____ cans or bottles per dayAlcohol average # drinks during the week _____ type ____Alcohol average # drinks on the weekends _____ type ____THANK YOU FOR YOUR COOPERATION ................
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