Sleep Consult

Date:

Name (Last, First, M.I.):

M F

DOB:

CHIEF SLEEP COMPLAINT

Briefly describe your primary sleep disturbance

Difficulty Falling Asleep
Snoring
Restless Sleep
Difficulty Staying Asleep
Excessive Daytime Sleepiness
Periods of not breathing normally at night
OTHER (Please describe):

MEDICAL HISTORY

Have you ever been diagnosed with any of these conditions? (Check those that apply)

High Cholesterol
Asthma
Stroke
Hypertension (High blood pressure)
GERD (heartburn)
Diabetes
TBI
Hypothyroidism
Heart Failure
PTSD
Depression
Irregular Heartbeat
Anemia/Low Iron
Anxiety
Peripheral Vascular Disease
Nightmares
Recent weight gain - If yes, lbs gained
COPD
Headaches

Please list other chronic Medical Issues:

SOCIAL HISTORY

Tobacco Yes No

   If yes, how many years?

   How many hours before bedtime is your last use?

Caffeine Yes No

   If yes, how many beverages per day?

   How many hours before bedtime is your last use?

Alcohol Yes No

   If yes, how many beverages per day?

   How many hours before bedtime is your last use?

Exercise Yes No

   How many hours per week?

   How many hours before bedtime do you exercise?

Supplements Yes No

    Type:

    Supplement use per week?

    How many hours before bedtime is your last use?

WORK SCHEDULE

Do you work day or night shift? Day shift    Night shift

Do you work a fixed schedule or change shifts? Fixed Schedule   Rotating Schedule

Retired/Not Working

FAMILY HISTORY

(Does anyone in your immediate Family have any of the following?)

Obstructive Sleep Apnea   Yes No

Restless Legs Syndrome    Yes No

Snoring    Yes No

Narcolepsy     Yes No

Insomnia     Yes   No

SLEEP MEDICATIONS

Do you currently use or have used in the past any of the following medications for sleep? Please check all that apply

1.  Zolpidem (Ambien)     Yes No

    Currently using?   Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep?   Yes No

2.  Eszopiclone (Lunesta)     Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

4.  Trazadone Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

5.  Amitriptyline (Elavil)     Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

6.  Quetiapine (Seroquel) Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

7.  Diphenhydramine (Benadryl) Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

    Currently using? Yes No

    If currently using, how often do you take it?
      <1/wk 1/wk 2-6/wk 7/wk

    Did it help your sleep? Yes No

SURGICAL HISTORY

Have you had surgery on your upper airways? (tonsillectomy, septoplasty, UPPP, sinuses, etc.) Yes No

Year

Type of Surgery

Why?

Have you ever had a sleep study? Yes No

If Yes, when?

What was the diagnosis?

Do you have a CPAP? Yes No

Does it help? Yes No

SLEEP-RELATED SYMPTOMS

Please answer by checking YES or NO

Difficulty falling asleep? Yes No

Difficulty staying asleep Yes No

Wake up frequently at night   Yes No

Snoring   Yes No

Non-refreshing sleep   Yes No

Daytime sleepiness   Yes No

Stop breathing at night   Yes No

Waking up short of breath   Yes No

Waking up choking/gasping   Yes No

Heartburn at night    Yes No

Nighttime nasal congestion   Yes No

Sweaty at night   Yes No

Dry mouth in the morning   Yes No

Urination at night    Yes No

   If yes, average times per night : /Night

Uncontrollable urge to sleep Yes No

Muscle weakness w/ emotional experience Yes No

Your brain wakes up before your body and you can't move   Yes No

Fall asleep unexpectedly   Yes No

Vivid dreaming at sleep onset   Yes No

Legs feel restless   Yes No

Unpleasant sensation in legs   Yes No

Sensation is worse at night   Yes No

Sensation worse with inactivity   Yes No

Sensation improves with movement   Yes No

Sleep walking   Yes No

Sleep talking   Yes No

Unusual movements during sleep   Yes No

Dream enacting behavior   Yes No

SLEEP-WAKE SCHEDULE

Please describe your typical sleep period

WeekDAYS

Average Bedtime? (In bed with intent to fall asleep) o'clock

How long does it take you to initially fall asleep? minutes

Final wake time? o'clock

Average # of nighttime awakenings?

On average, how long does it take to return to sleep?

WeekENDS      Check box if the same as weekdays

Average Bedtime? (In bed with intent to fall asleep) o'clock

How long does it take you to initially fall asleep? minutes

Final wake time? o'clock

Average # of nighttime awakenings?

On average, how long does it take to return to sleep?

Do you nap on the weekends? Yes No

If yes, what time and how long do you nap?

FATIGUE

Please indicate on a scale of 1-10 (with 0 being "No Fatigue" and 10 being "Severe Fatigue" your fatigue over the past 2 weeks.  

EPWORTH SLEEPINESS SCALE

How likely are you to fall asleep in the following situations?

0 = Never     1 = slight chance     2 = moderate chance     3 = high chance

Sitting and reading
0     1     2     3

Watching TV
0     1     2     3

Sitting, inactive in a public place (e.g. theater or a meeting)
0     1     2     3

As a passenger in a car for an hour without a break 
0     1     2     3

Lying down to rest in the afternoon when circumstances permit
0     1     2     3

Sitting and talking to someone
0     1     2     3

Sitting quietly after a lunch without alcohol
0    1     2     3

In a car, while stopped for a few minutes in the traffic
0     1     2     3

    Total Score out of 24 =