Parkinson'S Desease Sleep Evaluation Form
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1Parkinson’s Disease Sleep Evaluation
Patient Name:
Doctor:
Start Date:
End Date:
Sleep Scale
Notes
1.
I have quality sleep through the night
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5
2.
It’s difficult for me to fall asleep
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5
3.
I wake up in the middle of the night
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5
4.
I have restless arms/legs at night that disrupt sleep
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5
5.
I fidget in bed
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5
6.
I have upsetting dreams
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5
7.
I have upsetting hallucinations while trying to sleep
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5
8.
I get up at night to go to the bathroom
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5
9.
I wake up because of numbing/tingling in my legs/arms
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5
I have painful muscle cramps during the night
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5
10.
I fall asleep during the day
11.
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5
I feel sleepy when I wake up in the morning.
12.
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5
13.
14.
15.
Additional Notes
Notes:
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