Sleep History Questionnaire (Page 2 of 4) in pdf

Sleep History Questionnaire Page 2

NAME: ____________________________________________

PAGE 2

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C. SLEEP PATTERN

1. Circle the days of the week you work:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

2. ON WORKDAYS

a. What time do you go to bed:

b. What time do you get out of bed:

3. ON WEEKENDS & HOLIDAYS

a. What time do you go to bed:

b. What time do you get out of bed:

4. How long does it take for you to fall asleep?

5. How many times a night do you awaken?

a. How long do the awakenings last?

b. List any symptoms associated with the awakenings: _____________________________

_______________________________________________________________________

6. SLEEP TIME

a. How many hours do you usually sleep?

(do not include hours spent in bed awake)

b. How many hours does it take to make you feel rested?

c. How many daytime naps do you take per week?

7. SLEEP QUALITY

a. Do you feel unrefreshed and still sleepy upon awakening?

YES

b. How long does it take to fully awaken in the morning?

8. In the daytime, are you chronically sleepy, fatigued or tired?

YES

9. Grade your tendency to FALL ASLEEP during the following situations:

(0=would never sleep, 1=slight chance of sleeping, 2=moderate chance of sleeping, 3=high chance of sleeping)

a. Sitting and reading

b. Watching TV

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

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

e. Lying down to rest in the afternoon

f. Sitting and talking to someone

g. Sitting quietly after lunch without alcohol

h. In a car, while stopped for a few minutes

Sleep History Questionnaire Page 2