Sleep History Questionnaire Page 3
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4NAME: ____________________________________________
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D. SLEEP AND BREATHING
1. Do you snore?
YES
NO
2. Is your snoring broken by hesitations, gasps and snorts?
YES
NO
3. Are the hesitations long enough to frighten your sleep partner?
YES
NO
4. Has your snoring driven your bed partner from the bedroom?
YES
NO
5. Do you awaken with a dry mouth?
YES
NO
6. Do you awaken with headaches?
YES
NO
E. INSOMNIA
1. Do you have trouble falling or staying asleep?
YES
NO
2. Do you worry about being able to fall asleep on time?
YES
NO
3. Do you feel sleepy prior to getting into bed?
YES
NO
4. Does your mind race with thoughts when lying awake?
YES
NO
5. Do daytime worries keep you awake at night?
YES
NO
6. Does pain disturb your sleep?
YES
NO
7. Does heat, cold, hunger or thirst disturb your sleep?
YES
NO
8. Is your insomnia the primary reason your life is in disarray?
YES
NO
9. Do you rely on a sleeping medication?
YES
NO
10. Do you watch TV, read, or work in bed?
YES
NO
11. Do you frequently travel across 2 or more time zones?
YES
NO
F. SLEEP DISTURBANCES
1. Do you experience unpleasant leg sensations at bedtime?
YES
NO
2. Do you kick or jerk your legs and/or arms during sleep?
YES
NO
3. Do you have sweats or awaken from sleep feeling flushed?
YES
NO
4. Do you awaken with a bitter or acid taste?
YES
NO
5. Do you frequently have nightmares or vivid dreams?
YES
NO
6. Do you grind your teeth or have bitten your cheek during sleep?
YES
NO
7. Have you ever walked or talked in your sleep?
YES
NO
8. Have you ever been unable to move for a few moments after awakening?
YES
NO
9. Have you ever seen or felt things from your dreams after awakening?
YES
NO
10. Have you ever experienced weakness when laughing or angry?
YES
NO
11. Have you ever had unusual movements or behaviors during sleep?
YES
NO
Describe: __________________________________________________________________
G. PERSONAL HABITS
1. Do you use tobacco now or have you in the past?
YES
NO
a. If yes, how many per day and for how many years?
b. If yes, what time of day is your last use?
2. Do you drink alcohol?
YES
NO
a. If yes, how many drinks? _______ per day / per week / per month (circle one).
b. If yes, what time of day is your last drink?
3. How many caffeinated beverages do you drink per day?
a. If yes, what time of day is your last drink?
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