Age
Race M/F
Sleepy:
Y/N
Sleep schedule:
Symptoms
Tired:
Y/N
Work days
Snoring:
Y/N
Fatigue:
Y/N
Bedtime: _____ am/pm
Frequent snoring
Y/N
Sleepy during day with:
Time. to sleep _____
Heard outside room
Y/N
– Sitting & Reading
Wake time: _____am/pm
Bothering bed partner
Y/N
– Watching TV/movie
Total sleep time _____
Wake up gasping for air?
Y/N
– Driving
Alarm Y/N
Witnessed apnea:
Y/N
– Passenger in car
Off days
Mouth breathing
Y/N
– At work/school
Bedtime: ______ am/pm
Nasal congestion
Y/N
– Poor concentration
Wake time: ______ am/pm
AM headaches
Y/N
– MVA’s from EDS ____ (#)
Alarm Y/N
GERD
Y/N
– Close calls ______(#)
Sweating at night
Y/N
Supine or lateral sleep
Epworth sleepiness score ____
Arousals: Y/N; ___x/night
Fatigue severity score _____
Time to fall back asleep: _____
Refreshed in am: Y/N
Cause of arousals?
Time most tired __________
Naps: Y/N
Naps: _____day/week
How often?
_____hrs/day
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