Sleep History Questionnaire Page 4
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PAGE 4
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H. FAMILY HISTORY
AGE
MEDICAL CONDITIONS
Father:
Mother:
Sibling 1:
Sibling 2:
Sibling 3:
(continue below if necessary)
1.
List any relatives who have sleep problems or snore?
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I. PERSONAL HISTORY
(Check any and all that apply)
skipped heart beats
heart failure
heart attack
heart murmur
high blood pressure
thyroid problems
diabetes
stroke
epilepsy
headaches
emphysema
sinusitis
nasal congestion
deviated nasal septum
enlarged tonsils
allergies
asthma
glaucoma
depression/anxiety
Bipolar disorder
J. BED PARTNER QUESTIONNAIRE
(Please have your bed partner check any and all that apply)
Light snoring
Sleep walking
Leg or body twitching
Heavy snoring
Sleep talking
Leg jerking
Pauses in breathing
Bed-wetting
Daytime sleepiness
Snorting
Head rocking/banging
Daytime confusion
Teeth grinding
A shaking fit
Depression/anxiety
1. Provide additional detail regarding any of the above. Please describe the activity, the time it
occurs, and how often it occurs.
K. ADDITIONAL INFORMATION
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Parent category: Life