We welcome you as our patient

Name: ______________________________
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
Even if you have not done some of these activities recently, try to think how you would react.
Use the following scale to choose the most appropriate number rating for each situation.

0 = would NEVER doze 1 = SLIGHT chance of dozing 2 = MODERATE chance of dozing 3 = HIGH chance of dozing 4. As a passenger in a car for an hour without a break 5. Lying down to rest in the afternoon when circumstances permit 7. Sitting quietly after lunch (without alcohol) 8. In a car, while stopped for a few minutes in traffic Berlin Questionnaire
Please check the box that best answers each question for all three Categories.  Louder than talking  Can be heard in next room 4. Does your snoring bother other people? 5. Has anyone ever noticed you stop breathing in your sleep?  Almost daily 6. How often do you feel tired after sleeping? 7. Do you feel tired during your waking time? 8. How often do you nod off or fall asleep while driving? FOR OFFICE USE ONLY
10. Is your BMI (Body Mass Index) over 30? ___ High | ___ Low
Name: ___________________________________________________ Date: __________________
Birthdate: ______________ Age: _______
Occupation: ___________________________
Gender: _________
Height: ________
Weight: ___________ Weight Last Year: __________
Marital Status: Single
Referring Doctor: _____________________ Primary Care Doctor: _________________________
What is (are) your current, main sleep complaint(s)? Check only the ones that apply.
 Loud snoring
 Pauses in breathing while asleep  Awaken gasping for breath  Awaken from sleep still tired  Difficulty falling asleep  Unusual or unwanted behaviors during sleep, please explain: _______________________________ ___________________________________________________________________________________ Previous Sleep Evaluations & Treatment - Answer all that Apply
(If this is your first evaluation, please skip to the next section)
1. My last sleep evaluation was (check one): 2. I was diagnosed with: ________________________________________________________________ 3. I use a CPAP or Bi-Level device (circle one): 4. I have had surgery to treat a sleep disorder (circle one): If yes, what type of surgery was performed? _____________________ Current Medication List
Please list all current medications you take, prescribed and OTC (Over-the-Counter) below, including
vitamins & supplements. Attach separate page if needed.

Please list known allergies: ______________________________________________________________
Name: _______________________________
Patient Medical History
Please answer all questions to the best of your ability, checking either YES or NO.
Have you ever had any of the following medical conditions? COPD (Emphysema/Chronic Bronchitis)  YES  NO Sleep & Breathing
1. Do you snore?
3. Is your snoring broken by hesitations, gasps and snorts? 4. Are the hesitations long enough to frighten your sleep partner?  Never  Sometimes  Always 5. Has your snoring driven your bed partner from the bedroom? 8. Do you awaken choking or gasping for air? 9. Have you ever fallen asleep while driving or stopped in traffic? 10. When you wake, are your sinuses stuffed or clogged up? 12. Do you wake up feeling your heart pounding or racing? Sleep Disturbances
13. Do you experience unpleasant leg sensations at bedtime?
14. Do you kick or jerk your legs and/or arms during sleep? 15. Do you have sweats or awaken from sleep feeling flushed? 16. Do you awaken with a bitter or acid taste in your mouth? 17. Do you frequently have nightmares or vivid dreams? 18. Do you grind your teeth or have bitten your cheek during sleep? 19. Have you ever walked or talked in your sleep? 20. Have you ever felt unable to move after awakening? 21. Have you ever seen or felt things from your dreams after awakening?  Never  Sometimes  Always 22. Have you ever experienced weakness when laughing or angry? 23. Have you ever had unusual movements or behaviors during sleep? 24. Outside of childhood, have you ever wet the bed? 26. Is your sleep disturbed by a household member? Social Habits
1. Do you use tobacco (now or past)?
a) If yes now, how many per day and for how many years: b) If yes now, what time of day did you last smoke: d) If quit, how many per day and for how long: 2. Do you drink alcohol (includes beer, wine & liquor)? a) If yes, how many drinks - per (circle frequency): b) If yes, when was your last drink (date & time): 3. Do you drink/take caffeine (includes caffeine pills, energy drinks, coffee, tea & soda)? a) How many caffeinated beverages/pills per day: 4. What are your living arrangements? If not alone, what are your sleeping  Same Room, Separate Beds  Same Room, Same Bed 5. Occupation: ______________________  Employed  Unemployed  Retired  Rarely/Never  1-3 x/week  3-5 x/week  5-7 x/week 7. Do you use illicit/recreational drugs?  YES  NO If yes, how often ________; last used ________ b) Cocaine/Crack/Amphetamine  YES  NO If yes, how often ________; last used ________ c) Heroin/Morphine/Methadone  YES  NO If yes, how often ________; last used ________  YES  NO If yes, how often ________; last used ________  YES  NO If yes, how often ________; last used ________

Source: http://www.jacks.ws/sites/default/files/pdf/sleep.pdf


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