Sleep History Questionnaire printable pdf download

Sleep History Questionnaire

Name: ____________________________________________ Date: _____________________

Birthdate: ___________________ Age: ________ Occupation: ________________________

Sex: ______________Height: _________ Weight: ________ Weight Last Year: __________

Referring Doctor: ______________________ Family Doctor: __________________________

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Describe your sleep problem: _____________________________________________________

______________________________________________________________________________

What results do you expect: ______________________________________________________

______________________________________________________________________________

A. MEDICATION SURVEY

Please list all PRESCRIPTION and NON-PRESCRIPTION medications you’re currently taking.

MEDICATION

REASON TAKEN

DOSE

ALLERGIES: _________________________________________________________________

B. PLEASE LIST ALL PAST OR PRESENT MEDICAL CONDITIONS OR SURGERIES

Sleep History Questionnaire