Sleep Evaluation/clinicals
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1SLEEP EVALUATION / CLINICALS
Today’s Date: ______________________
Patient Name: ____________________________________________________ Date of Birth: ______/_______/_______
Gender: M _____ F _____
Height: _________ Weight: _________
Blood Pressure: _______________________
Please check any of the following you may have:
Morning Headaches
Heart Disease
Stroke
Diabetes
Frequent Urination at Night
ADD/ADHD
Depression
Hypertension
Erectile Dysfunction
Fibromyalgia
Overweight
Heart Failure
Atrial Fibrillation
Renal Failure
COPD
GERD
Grinding Teeth (Bruxism)
Restless Legs (RLS)
Memory Loss
Low Testosterone
Please check Yes or No to the following questions:
1. Do you snore or have been told that you snore?
YES
NO
2. Do you often feel tired, fatigued, or sleepy during the daytime?
YES
NO
3. Has anyone observed you stop breathing or gasp for air during your sleep?
YES
NO
4. Do you have or are you being treated for high blood pressure?
YES
NO
If you answered Yes to 2 or more of the above, please continue:
Never
Slight chance
Moderate chance
High Chance
Epworth Sleepiness Scale
doze off
of dozing
of dozing
of dozing
1. Do you get sleepy, or doze off, while sitting and reading?
0
1
2
3
2. Do you get sleepy, or doze off, while watching TV?
0
1
2
3
3. While sitting or inactive in a public place
0
1
2
3
?
4. As a passenger in a car for an hour without a break?
0
1
2
3
5. Lying down to rest in the afternoon?
0
1
2
3
6. Sitting and talking to someone?
0
1
2
3
7. Sitting quietly after lunch without alcohol?
0
1
2
3
8. In a car, while stopped for a few minutes at a traffic light?
0
1
2
3
Total Score
Have you ever been diagnosed with Sleep Apnea?
YES
NO
Are you currently using CPAP?
YES
NO
(or any other apnea/snoring device)
Are you currently taking any sleeping aids (prescribed or OTC)?
YES
NO
Are you currently taking any prescribed pain medication?
YES
NO
Untreated Sleep Disorders are related to many health and financial complications:
*Diabetes *Premature death *5X the risk of heart attack *2X the risk of stroke *Weight gain *6X the risk of a serious
automobile accident *Increased risk of cancer *Hypertension *Depression *Erectile dysfunction *Daytime fatigue
*ADHD *GERD *Decreased job performance *RLS/PLM *Increased cost of healthcare *Chronic/migraine headaches
*Post-surgical complications/death *Chronic pain *Weakened immune system *Renal failure *Heart disease
Provider Signature/Initials*__________________________________________
*To be filed for reference and review in patient’s chart notes
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