Sleep Questionnaire :: Surrey Sleep Clinic and Laboratory

To maintain your confidentiality do not enter your full name or full date of birth

Last Name:

Year of Birth:

Referring Doctor:

Do you have BC (MSP) Care Card?

Yes

Do you have extended benefits? (Such as Blue Cross, Sun Life, Green Shield, etc.)

Yes

Your Height:

Your Weight:

Why did your doctor refer you to Surrey Sleep Clinic?

MEDICAL HISTORY

Do you have history of any other medical illness/psychiatric disorder? – Please list below

Do you take any Medications? – Please list below

Do you have any Allergies or Major Side Effects to any Medications? – Please list below

EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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 choose 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

SITUATION

SLEEP APNEA: This means pauses in your breathing during sleep

SLEEP SCHEDULE

IT IS VERY IMPORTANT THAT YOU ANSWER EACH OF THE FOLLOWING QUESTION EVEN IF YOU ARE UNAWARE OF ANY SLEEP PROBLEMS. FOR YES OR NO ITEMS CHOOSE ONLY ONE ANSWER.

	Work/School Days	Days off/Weekends
Bedtime (pm or am)
Wake up time (pm or am)
Average hours of sleep per night

How long does it take for you to fall asleep?
Does anything stop you from falling asleep (eg, pain, restless legs or thinking too much etc)? If yes, please type 25 words or less:
On the average, how often do you wake up during the night?
Do you know why you wake up during the night?	Yes	No
If Yes, type the reason(s) for these awakenings - 25 words or less:

SHIFT WORK

Are you a Shift Worker? (If No, please proceed to next section)		Yes	No
What shifts do you work?	Morning	Afternoon	Graveyard
Which shift do you prefer?	Morning	Afternoon	Graveyard

	Morning Shift	Afternoon Shift	Night Shift	On days off
Work Time
Bedtime
Wake-up Time

EXCESSIVE SLEEPINESS

Do you feel tired on waking up?	Yes	No
Fill in a number on a scale of 0 to 10 indicating how rested you feel when you awaken for the day with 10 being most rested and 0 being totally unrested:
Do you get urges to fall asleep during the day?	Yes	No
Do you nap during the day?	Yes	No
IF YES: How often?

RESTLESS LEGS OR LIMBS:

This means having achy, pins and needles or crawling feelings in your legs or arms.

Do you have Restless Legs?	Yes	No
Do you have Restless Legs at bedtime?	Yes	No
Does the sensation stop you from falling or staying asleep?	Yes	No
Do your arms, legs or body jerk while falling asleep?	Yes	No
Any additional information about your restless legs/arms? 25 words or less.

PARASOMNIAS:

Briefly, this means abnormal movements, behaviors, emotions, perceptions, and dreams during sleep or while falling asleep. For example, sleep walking, sleep talking, sleep terrors, nightmares, confusional arousals, sleep eating, aggressive behavior during sleep, sleep paralysis etc.

AGGRESSIVE BEHAVIOR DURING SLEEP

Do you behave in a violent or aggressive way during sleep?	Yes	No
Have you ever injured or tried to injure your bed partner during sleep?	Yes	No
Have you ever injured yourself during sleep?	Yes	No
Has anyone observed you making unusual movements while asleep?	Yes	No
Any additional information about aggressive behavior or movements during sleep? 25 words or less.

SLEEP PARALYSIS:

This means "feeling paralyzed" as if you were unable to move any part of your body while falling asleep, on waking up or coming out of a dream.

Do you have Sleep Paralysis?	Yes	No

CATAPLEXY

This means losing muscle strength or become very weak during or immediately while experiencing sudden emotion such as laughter, excitement, surprise or anger. This loss of muscle strength may result in behavior such as dropping things, weakness of the facial muscles, having to sit or falling down.

Do you have Cataplexy?	Yes	No

BED WETTING

Have you had any bed wetting after the age of 18?	Yes	No
How many times a week or month?
At what age did your bedwetting appear?

Sitting and reading	0	1	2	3
Watching TV	0	1	2	3
Sitting, inactive in a public place (e.g. a theatre 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 (calculated from above questions):

Do you Smoke?	Yes	No
If Yes, how much?
Do you use marijuana?	Yes	No
Do you use any street drugs?	Yes	No
Do you drink alcohol?	Yes	No
Do you drink alcohol to go to sleep?	Yes	No
How many alcoholic drinks do you drink? (for example 1/d or 1/week etc)
How much coffee do you drink? (for example 1/d or 1/week etc)
How much tea do you drink? (for example 1/d or 1/week etc)
How much cola do you drink? (for example 1/d or 1/week etc)
How much chocolate do you take? (for example 1/d or 1/week etc)

Sleep Questionnaire

Surrey Sleep Clinic and Laboratory

ONLINE SLEEP HISTORY FORM