Sleep Disorder Diagnostic Form printable pdf download

Sleep Disorder Diagnostic Form

Name:

DOB:

Height:

Weight:

Gender:

BMI:

Blood Pressure:

Health History

(Please Check All That Apply)

I have frequent urination at night

I smoke cigarettes on a regular basis. Number per day:

I drink coffee on a regular basis. Number of cups per day:

I drink alcohol before bed/as a nightcap. Number of drinks per night:

I eat a lot of spicy food/I get indigestion often

I am overweight

I suffer from depression

I have a history (or family history) of heart disease

I have high blood pressure

I have high cholesterol

I have diabetes

I am on medication:

Sleep History

(Please Check All That Apply)

I sleep fitfully (tossing and turning)

I snore loudly enough for others to hear/wake up

I regularly stop breathing in my sleep

I choke or gasp in my sleep

I grind my teeth while I sleep

I sweat in my sleep

I frequently wake up with headaches

I regularly get tired throughout the day

I get tired or doze while sitting, watching TV in the day, riding in a car, after meals, etc.

I have insomnia

I wake up multiple times a night and can’t get back to sleep

I get less than 8 hours of sleep a night (on average)

I get more than 8 hours of sleep a night (on average)

I often feel tired and unrested in the morning

Sleep Disorder Diagnostic Form