Sleep Study Questionnaire (Continued)
Did you have a sleep problem as a child?
If yes, describe
Do you currently have nightmares or night terrors?
Do you grind or clench your teeth at night?
Did you frequently wet the bed as a child?
Have you ever wet the bed as an adult?
Have you ever been told that you walk in your sleep?
Have you recently walked in your sleep?
Have you ever been told you make unusual movements such a
swinging arms about, acting out dreams, etc. during
Have you ever felt sudden muscle weakness when you laughe
Have you ever had a sleep related driving accident or a near m
MEDICAL AND SURGICAL HISTORY:
Mark any of the following disorders that you have been
diaWlosed with (active problem or cured)
d or got angry?
Restless Legs Syndrome
Coronary Artery Disease
Congestive Heart Failure
Reflux Disease (GERD)
Post Traumatic Stress Disorder
PREPARED BY (Signature
PATIENT'S IDENTIFICATION (For typed or written e
give: Name,-last, fIrst, middle; grade; date; hospital or m
MEDICAL RECORD SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of the Surgeon General
Have you ever been unable to move your body just as you were falling asleep or waking up?
Have you ever had exceptionally vivid dreams just as you were falling asleep or waking up?
Mark any of the following disorders that an
immediate family member has been diagnosed
with (active problem or cured)
(Continue on reverse)
DA FORM 4700, FEB 2003
EDITION OF MAY 78 IS OBSOLETE CRDAMC OP 501
1 May 10 (cont)