ࡱ> qspq` bjbjqPqP n^:: ppppppp\$33333I&44444;*;<IIIIIII$Jh"MT9Ip<q:N;<<9Ipp44NICCC<Rp4p4IC<ICC#EppgE44 D3g?N;EEdI0I;E,vMC4vMgEvMpgE <<C<<<<<9I9IC <<<I<<<<D 33D4xXpppppp  Vijay Pethkar, MD Comprehensive Sleep Center Accredited by the American Academy of Sleep Medicine 780 North Mt. Juliet Road Mt. Juliet, TN 37122 P: 615-758-9273 F: 615-758-4821 Sleep Questionnaire for New Patient Name:____________________________Age:_____________________________Date:_____________________________Primary Physician___________________1.Do you feel excessively sleepy during the day?Yes_____No_____2.Has someone told you that you snore?Yes_____No_____3.Has someone told you that you stop breathing inYes_____No_____your sleep?4.Do you ever wake up with a choking sensation?Yes_____No_____5.What time do you normally go to bed?________________6.How long does it take you to go to sleep?________________7.Do you wake up at night? What wakes you up?Yes_____No_____ 8. What time do you wake up in the morning? ________________ Did you ever experience an irresistible desire to fall asleep? Yes_____No______ Did you ever experience inability to move one or both sides of your body or limbs when you are about to fall asleep or wake up from sleep?  Yes_____No_____ 11. Did you ever experience weakness in you limbs, buckling of knees, sagging of the jaw or any other unusual symptoms when you were happy and laughing or sad or angry?  Yes_____No_____ 12. Do you ever see or feel things that are not there when you are about to fall asleep or wake up from sleep?  Yes_____No_____ 13. Do you have a achy, crawling sensation in your legs, especially in the evenings and bed time, when you cannot sit still and want to move your feet or walk around?  Yes_____No_____ 14. Has anyone told you that you jerk and twitch during sleep?  Yes_____No_____ 15. Has anyone told you that you kick, yell, or have violent activities during sleep?  Yes_____No_____ 16. Do you regularly nap during the day and if so, how long?  Yes_____No_____ ___________________________________________ 17. Do you consume alcohol regularly?  Yes_____No_____ 18. Do you drink caffeinated beverages such as coffee, Tea, Coke, Pepsi? If so, how much?   Yes_____No_____ Please list all medical conditions:  Please list all medications including over the counter medications:  Epworth Sleepiness Scale Name: ________________________ Age:________ Date:____________ Male/Female How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to chose the most appropriate number for each situation: 0= would never doze 1= slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing SituationChance of dozingSitting and reading_______Watching TV_______Sitting, inactive in a public place(e.g.- movie theater, meeting)_______As a passenger in a car for an hourwithout a break_______Lying down to rest in the afternoonwhen circumstances permit_______Sitting and talking to someone_______Sitting quietly after lunch withoutalcohol_______In a car, while stopped for a few minutesin traffic_______ Total Score:  /de # F o . / ; ? 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