Sleep Intake Form Page 2
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3Sleep History
Have you ever had your sleep evaluated before?
Sleep Study Date: ____/____/_________
What were you told your final assessment (diagnosis) was?
What treatment options were you offered?
What prompted today’s evaluation?
Have you had any oral surgeries to treat your sleep symptom?
Do you work swing-shift or nighttime shifts?
Have you ever tried any of the
Please check the appropriate box below:
following to help improve your sleep
breathing?
High Blood Pressure
Yes
No
CPAP
Yes
No
Heart Disease
Yes
No
Weight Loss
Yes
No
History of Heart Attack or Stroke
Yes
No
Nose Cones or Strips
Yes
No
Mood Disorder
Yes
No
Side Sleeping
Yes
No
Impaired Thinking
Yes
No
Surgical Treatments
Yes
No
Insomnia
Yes
No
Epworth - How likely are you to doze off or fall asleep in the
SCALE
following circumstances, in contrast to feeling just tired?
0 - Would Never Fall Asleep
1 - Slight Chance of Dozing
This refers to your usual way of life in recent times.
2 - Moderate Chance of Dozing
3 - High Chance of Dozing
Sitting and reading
0
Watching television
0
Sitting inactive in a public place (i.e. a theater)
0
A passenger in a car for an hour without a break
0
Lying down to rest in the afternoon when possible
0
Sitting quietly after a lunch without alcohol
0
In a car while stopped for a few minutes in traffic
0
Overall quality of sleep- poor, average, good
TOTAL
0
Patient Signature _______________________________________
Date: ____/____/________
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