Sleep Questionnaire Evaluation Form printable pdf download

Sleep Questionnaire Evaluation Form

Sleep Questionnaire

Name: ________________________________________

Date: ______________________

Do you snore?

Have you been told you stop breathing or gasp for air when sleeping?

Have you awakened with your heart racing?

Do you wake up often throughout the night?

Do you wake up with headaches?

Do you sweat at night?

Do you wake up more than once to urinate?

Do you wake up tired or often feel tired throughout the day?

Have you recently gained weight or have difficulty losing weight?

Do you suffer from acid reflux?

Do you have high blood pressure or take medication for high blood pressure?

Do you have heart disease?

Do you have diabetes?

Are you short tempered of get irritated easily?

Do you smoke?

Epworth Sleepiness Scale

Use the following scale to choose the most appropriate answer for each situation

0= Would never fall asleep

1= Slight chance of falling asleep

2= Moderate chance of falling asleep

3= High chance of falling asleep

Situation chance of dozing:

Sitting and reading

Watching TV

Sitting inactive in a public place (e.g. a theatre or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

Total

Sleep Questionnaire Evaluation Form