Center for Sleep & Wake Disorders
Follow-up Questionnaire

Please fill out this form and then click "Submit" when finished
(*=required field)
First name:*    Last name:*           
Date of Birth:*  
Current Primary Care/Internist:*   Date of last physical:*  
Current weight (in pounds):   (Please only enter numbers; if unknown, please leave blank)
Height (feet):*     Height (inches):*   
What is the main sleep problem that you are seeing us for?*   
New medical problems or changes in old ones:   

Please answer these questions about your sleep and wakefulness since your last visit:
How has your sleep problem been since your last visit?*           
Please use this space for any additional info about your condition since your last visit:

What time are you getting in bed, on average?*   
About what time do you turn off the lights and try to go to sleep?  
Approximately how long does it take you to fall asleep?
About how many hours of sleep do you get on an average night?*   
How many awakenings are you experiencing on an average night? 

What are the times of typical awakenings?
8pm-10pm    10pm-12mid    12mid-2am    2am-4am    4am-6am    6am-8am
 8am-10am    10am-12n    12n-2pm    2pm-4pm    4pm-6pm    6pm-8pm

What is the average duration of these awakenings?
 <5 min    5-15 min    15-30 min    30-60 min    60-90 min    90 min - 2 hours    >2 hours

Why do you think you awaken?  
Need to use bathroom bedpartner awakens you own snoring awakens you pets   no clear reason  other
If other, please elaborate:

What time do you get up on most workdays?*
What time do you get up on most weekends?*
How much variability is there from night to night?
How do you feel when you awaken in the morning?*   
Please rate your daytime sleepiness (0 is none, 5 is severe)*  

Over the past week how likely would you be to fall asleep in the following situations? (0 is not likely, 3 is very likely)
Sitting and reading* 0 1 2 3
Watching TV* 0 1 2 3

Sitting in a public place*

0 1 2 3

As a passenger in a car for an hour*

0 1 2 3

Lying down to rest in the afternoon*

0 1 2 3

Sitting and talking to someone*

0 1 2 3

Sitting quietly after lunch with no alcohol*

0 1 2 3

In a car, stopped for a few minutes in traffic*

0 1 2 3

Epworth Sleepiness Scale (Johns MW. Sleep 1991;14:540-545)

How many naps do you take per week?
 
Average nap length: 
Caffeinated beverages/day:   
Alcoholic beverages/week:   

Are you a current cigarette smoker?*     
        If yes, how many packs per day?      How often do you smoke within two hours of bedtime? 

Recreational drug use?:*     If yes, please elaborate:  


Do you use CPAP? (If no, skip to medications section)  
Is CPAP helping?   
Are you still snoring? 

How many nights per week do you use your CPAP? 
 
How many hours/night?

Please describe any problems you are having with your CPAP:


Please list your currrent medications, including any over-the-counter (OTC), vitamins, and supplements.
Please include dosages, times of day (e.g. morning, bedtime), and the prescribing physician if you have this information):

If none, please check here: 
 // If you have been seen by us in the previous 12 months, and there have been no changes to your medications, please check here:
Name of medication Dose Time(s) (e.g. morning / bedtime) Prescribing Doctor
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
If any additional meds, please enter here: