Medical Record-Supplemental Medical Data Page 2
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4RESPIRAnON:
How often do vou have or do the following:
Never
Sometimes
Routinelv
Snoring
Stop breathing when sleeoinl!.
Morning Headaches
Awaken gasping/choking
Dry Mouth
SLEEP SCHEDULE:
Weeknights
Weekends
What time do you go to bed?
What time do you get
UP
in the mornings?
How many hours of sleep do
YOU
get each night?
How many hours do you nap per day?
SLEEP HYGIENE:
WEIGHT HISTORY:
Do you usually feel well rested upon awakening?
Yes
No
Your weight at age 20
lbs.
Do you watch TV in bed?
Yes
No
Your weight at age 30
lbs.
Do you look at your bedroom clock at night?
Yes
No
Your weight at age 40
lbs.
Do you have arguments in bed?
Yes
No
Your weight at age 50
lbs.
Do you worry in bed?
Yes
No
Your weight at age 60
lbs.
Does sleep position affect your snoring?
Yes
No
Your heaviest weight
Ibs.
If yes, in what position do you sleep best?
atage
_
Do you currently do shift work?
Yes
No
Have you done shift work in the past?
Yes
No
If yes, do you have trouble sleeping
while performing shift work?
Yes
No
Does your spouse perfonn shift work?
Yes
No
INSOMNIA:
Answer the following questions assuming "night" means your major sleeping time.
Do you often have trouble getting to sleep at night?
Yes
No
What is the average number of minutes it takes you to fall asleep at night?
____.Minutes
Do you have long periods when you awaken and are not able to get back to sleep?
Yes No
If yes, how long are these periods of wakefulness when added together?
____Minutes What is the average number of
times per night you wake up?
Times
If yes, why do you awaken? (Circle):
Pain
Bathroom
Noise
Light
Nightmares
Difficulty Breathing
Night Terrors
Choking/Gasping
Are you bothered by waking up too early and not being able to go back to sleep?
Yes No
MOVEMENT:
Do you ever have restless legs (a strong desire to move your legs while at rest,
relieved with moving your legs, and the sensation returns when you rest your legs)?
Yes No
If yes, is this something that you think routinely interferes with your sleep?
Yes No
Do these symptoms occur more in the evening than any other times?
Yes No
Do you awaken yourself by kicking your legs, or other sudden movements, during the night?
Yes No
Has your partner ever complained of your legs kicking, or other movements, while asleep?
Yes No
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