WVSC Sleep Questionnaire WVSC Sleep Questionnaire 1 2 3 4 5 6 7 8 Name First Last Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Referring PhysicianFamily Physician Patient InformationHome PhoneWork PhoneCell PhoneDOB MM DD YYYY AgeSexMaleFemaleWeightPlease enter a value between 4 and 800.HeightNeck SizeMy Main Sleep Complaints (Check All That Apply) Stop Breathing During Sleep Trouble Sleeping at Night Sleepy All Day Unwanted Behaviors During Sleep Snoring I. Sleep PatternTypical BedtimeWork DayWeekends (off days)Typical amount of time it takes to fall asleepWork DaysWeekends (off days)List any activities that you normally do during nighttime awakenings (restroom, eat, tv, etc)Work DaysWeekends (off days)Typical amount of time it takes to fall back asleep after an awakeningWork DaysWeekends (off days)Typical wake up timeWork DaysWeekends (off days)Desired wake up timeWork DaysWeekends (off days)How do you usually awaken (alarm clock, kids, etc)Work DaysWeekends (off days)Typical time you get out of bedWord DaysWeekends (off days)Total amount of sleep per nightWork DaysWeekends (off days) II. Sleep HabitsCheck the column that you feel best describes your situation.I usually watch TV or read in bed prior to sleep Often Sometimes Never I frequently travel across two or more time zones Often Sometimes Never I drink alcohol prior to bedtime Often Sometimes Never I smoke prior to bedtime or when I awaken at night Often Sometimes Never I eat a snack at bedtime Often Sometimes Never I eat if I awaken during the night Often Sometimes Never I typically awaken to urinate during the night Often Sometimes Never I feel that I have insomia Often Sometimes Never I am unable to return to sleep easily if I awaken during the night Often Sometimes Never I awaken early in the morning still tired, but unable to return to sleep Often Sometimes Never I have been unable to sleep for several days Often Sometimes Never I experience a creeping/crawling or tingling sensation in my legs when I try to fall asleep Often Sometimes Never I cannot sleep on my back Often Sometimes Never I have trouble getting to sleep Often Sometimes Never I am awaken at night by pain Often Sometimes Never I wake up more than once during the night Often Sometimes Never At bedtime I feel sad and depressed Often Sometimes Never What type of pain?At night my heart pounds, beats rapidly or irregularly Often Sometimes Never I sweat a great deal at night Often Sometimes Never My sleep is disturbed by sadness or depression Often Sometimes Never I have nightmares (frightening dreams) Often Sometimes Never I have slept or been overwhelingly sleepy for several days at a time Often Sometimes Never I get very sleepy during the day and I struggle to stay awake Often Sometimes Never I now have trouble doing my job because of sleepiness or fatigue Often Sometimes Never III. BreathingCheck the column that you feel best describes your situation.I have been told that I stop breathing while sleeping Often Sometimes Never I awaken at night choking, smothering or gasping for air Often Sometimes Never I have been told that I snore Often Sometimes Never I have been awaken by my own snoring Often Sometimes Never My snoring or my breathing problem is much worse if I fall asleep right after drinking alcohol Often Sometimes Never My snoring or breathing problem is much worse if I fall asleep on my back Often Sometimes Never IV. RestlessnessCheck the column that you feel best describes your situation.I am a restless sleeper Often Sometimes Never I kick or jerk my legs and/or arms during sleep Often Sometimes Never I experience an inability to keep my legs still prior to falling asleep Often Sometimes Never I experience restlessness, tingling or crawling in my arms and/or legs Often Sometimes Never I talk in my sleep (adult) Often Sometimes Never I sleep walk (adult) Often Sometimes Never I grind my teeth in my sleep Often Sometimes Never V. Daytime SleepinessCheck the column that you feel best describes your situation.I take day naps Often Sometimes Never I have a tendency to fall asleep during the day Often Sometimes Never I have experienced lapses in time or blackouts Often Sometimes Never I have fallen asleep while driving Often Sometimes Never I often let someone else drive because I am sleepy Often Sometimes Never I have had auto accidents as a result of falling asleep while driving Often Sometimes Never I have driven to the wrong place and not remembered doing it Often Sometimes Never I performed poorly in school because of sleepiness Often Sometimes Never I have had injuries as a result of sleepiness Often Sometimes Never I have experienced an inability to move while falling asleep or waking up Often Sometimes Never I have experienced dreamlike images, sounds or hallucinations while falling asleep or waking up Often Sometimes Never I get sudden muscular weakness (or even a brief period of paralysis) when laughing, angry or in a situation of strong emotion Often Sometimes Never VI. Past Sleep Evaluation and TreatmentCheck the column that you feel best describes your situation.I have had a pervious sleep disorder evaluation Often Sometimes Never I have had daytime nap studies Often Sometimes Never I have had previous overnight sleep studies Often Sometimes Never I have been described a CPAP or Bi-Level machine for home use Often Sometimes Never I have had surgical treatment for a sleep disorder Often Sometimes Never When and where was your overnight sleep study? VII. Past Medical HistoryCheck all that apply. Hypertension (High Blood Pressure) Heart Disease Diabetes Stomach or Colon Problems Lung Problems/COPD/Asthma Reflux Fibromyalgia Glaucoma Numbness Fatigue, Weakness Hearing Impairment Alcoholism Stroke TIA "Light Stroke" Blackouts Seizures Back or join problems (Arthritis) Cancer Thyroid Problems Hepatitis Dizziness HIV Positive Depression or severe anxiety Chemical abuse or dependency Female Menstrual Periods Post Menopausal Male Erectile Dysfunction/Impotence Prostate Problems Hospitalizations (Past Year) List other past medical problems and dates List surgeries and dates Any special needs? VIII. Current Medical StatusMedications Dose Number of times a day IX. Family HistoryCheck if an immediate blood relatives have had any of the following. Cancer Diabetes Hypertension Heart Disease Thyroid Disease Stroke Anxiety Depression Sleep Apnea Narcolepsy Other ExplainX. Social HistoryOccupationUsual work hours a dayCaffeine Yes No Tobacco Yes No Alcohol Yes No Amount and FrequencyAmount and FrequencyAmount and FrequencyMartial Status Single Married Separated Divorced Widowed Do you... Sleep alone Share a bed with someone Share a bedroom, but have separate beds Share a dwelling, but have separate bedrooms Employment Status Employed Unemployed Retired Check all that apply My job requires driving a vehicle I work with dangerous equipment or substances I am a shift worker on rotating shifts I am permanent or long term third shift worker I am currently a student In the PAST 12 months you have had which of the following symptoms Frequent headaches Fainting or passing out Sudden loss of hearing or ringing in your ears Hoarseness for more than 2-4 weeks Nosebleeds Coughing for more than 2-4 weeks Coughing up blood Shortness of breath/wheezing Swelling in feet/ankles Chest pain, pressure,or heaviness Irregular heartbeat or sudden/fast heartbeat Difficulty swallowing or food "sticking" Change in wart, mole, or skin growth Frequent Heartburn/Indigestion Abdominal pain Frequent constipation Frequent diarrhea Rectal bleeding/black stool Difficulty urinating/incontinence Blood in urine Urination more than twice a night Pain in joints/bones Unusual bruising/bleeding Convulsions Difficulty concentrating
