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FBCH Sleep Disorders Intake Questionnaire
IMPORTANT: Click panel header to expand/collapse questionnaire in each panel. ***All FIELDS ARE REQUIRED.***
DEMOGRAPHICS

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Name:
DOD ID:
Age (16-100):
 
Best phone number:
Best email:
Marital Status:
Race:
If Other, please fill:
Are you leaving the area?:
If retirng, Estimated date of retirement (mm/dd/yyyy):


SOCIAL HISTORY

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What is the highest educational level that you completed?

Job Title:
1. Are you on flight/aviation status or dive status?
If yes, are you required to have a flight physical?
2. Are you currently assigned to the Soldier Recovery Unit?
If yes, Date/Location, Duration, and Case Manager:
3. Have you deployed?
If yes, Date/Location and Duration:
4. Have you been diagnosed with PTSD?
If yes, Date of diagnosis:
5. Have you been diagnosed with TBI (traumatic brain injury)?
If yes, Date of injury:
6. Do you use
What time is your last cigarette / dip / other of the day?
7. Do you drink alcohol?
How many drinks at one sitting?
How often (i.e. # of time / wk or month)?
8. Do you drink
Coffee (ounces / day)
Soda (ounces / day)
Tea (ounces / day)
Energy drinks (ounces / day)
What time do you typically drink your last caffeinated beverage of the day?
9. Do you Exercise?
How many times / week?
What time of day do you work out?
For how long?
10. How often do you travel that requires you to cross time zones? :


MEDICAL HISTORY

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1. Reason why you were referred? Please briefly describe the reason for your Sleep Medicine evaluation:
2. What is the specialty of your referring doctor?
If Other, please fill:
3. Have you seen a sleep provider before?
4. Have you had a sleep study in the Past?
Location/Date:
5. Are you using a device for sleep apnea?
6. Has anyone reported that you snore while using your CPAP system?
7. My mask
8. What are your pressure settings?
cmH2O (Enter N/A if no applicable)
9. What company provides you your supplies:
(Enter N/A if no applicable)
10. Are you using an Oral appliance for Sleep Apnea?
Settings:
(Enter N/A if no applicable)


11. Do you have or are receiving treatment for any of the following medical conditions? (check all that apply)
12. If waking up during the night to pee is checked, # of time:
13. If weight changes is checked, how much gained or loss:
14. If grinding teeth is checked, do you wear a mouth guard:
15. Because of your sleep problems, have you been considered for or been on disability, had work or school difficulties, had a driving problems or a motor vehicle accident?


Please check each item if you are experiencing any of the following symptoms. (check all that apply):

GROUP 1 -
GROUP 2 -
GROUP 3 -
GROUP 4 -
GROUP 5 -


SLEEP SCHEDULE, SLEEP PATTERNS, and BEDROOM ENVIRONMENT

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SLEEP SCHEDULE
Do you regularly work:
SLEEP PATTERNS (Write in the times or number of minutes. Please only use numbers and time (120 mins/ 0100-0200))

School or Work Week Weekends / Leave
What time do you get into bed to fall asleep?
How long, in minutes, does it take to fall asleep?
How many times do you wake at night?
How much time are you awake during the night?
Time on the clock when you finally wake up for day?
What time do you take your nap/how long?


BEDROOM ENVIRONMENT
Sleep with a partner:
Sleep with children:
Sleep with pets:
Exposure to light / Excessive heat:
Noise devices used in bedroom:
Feel safe in the sleep environment:


FATIGUE, SLEEPY OR TIRED, SLEEPINESS, and INSOMNIA

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FATIGUE: On a scale 1 to 10 how would you rate your fatigue over the past several weeks


Energetic No Fatigue
---------------------------------------------------------------------------------------------------------------------------------------------------------
Worst Possible Fatigue

None
Mild Fatigue
Moderate Fatigue
Severe Fatigue



SLEEPY OR TIRED: Some people have difficulty performing everyday activities when they feel tired or sleepy. The purpose of the below questions is to find out if you generally have difficulty carrying out certain activities because you are too sleepy or tired. In questions, when the words “sleepy” or “tired” are used, it means the feeling that you can’t keep your eyes open, your head is droopy, that you want to “nod off”, or that you feel the urge to take a nap. These words do not refer to the tired or fatigued feeling you may have after you have exercised.

1. Do you have difficulty concentrating on the things you do because you are sleepy or tired?
2. Do you generally have difficulty remembering things, because you are sleepy or tired?
3. Do you have difficulty operating a motor vehicle for short distances (less than 100 miles) because you become sleepy or tired?
4. Do you have difficulty operating a motor vehicle for long distances (greater than 100 miles) because you become sleepy or tired?
5. Do you have difficulty visiting with your family or friends in their home because you become sleepy or tired?
6. Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?
7. Do you have difficulty watching a movie or videotape because you become sleepy or tired?
8. Do you have difficulty being as active as you want to be in the evening because you are sleepy or tired?
9. Do you have difficulty being as active as you want to be in the morning because you are sleepy or tired?
10. Has your desire for intimacy or sex been affected because you are sleepy or tired?



SLEEPINESS– What would your chance of dozing be in any of the below situations? Please answer with and without treatment.
0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing


Before
After

Sitting and reading:
Watching TV:
Sitting, inactive in a public place (e.g. a theatre or a meeting):
As a passenger in a car for an hour without a break:
Lying down to rest in the afternoon when circumstances permit:
Sitting and talking to someone:
Sitting quietly after a lunch without alcohol:
In a car, while stopped for a few minutes in the traffic:


INSOMNIA:


1. How difficult is it for you to fall asleep?
None
Mild
Moderate
Severe
Very Severe
2. How difficult is it for you to stay asleep?
None
Mild
Moderate
Severe
Very Severe
3. Do you have problems waking too early?
None
Mild
Moderate
Severe
Very Severe
4. How NOTICEABLE to others do you think your sleeping problem is in terms impairing the quality of your life?
Not at all noticeable
A little
Somewhat
Much
Very much noticeable
5. How SATISFIED/DISSATISFIED are you with your current sleep pattern?
Very Satisfied
Satisfied
Moderately Satisfied
Dissatisfied
Very Dissatisfied
6. How WORRIED/DISTRESSED are you about your current sleep problem?
Not at all worried
A little
Somewhat
Much
Very much worried
7. To what extent do you consider your sleeping problems to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to work/daily chores, concentration, memory)?
Not at all worried
A little
Somewhat
Much
Very much Interfering

Are you currently prescribed treatment for Insomnia?


1. Past/Current Medical History / Please list: (stroke, irregular heart rate, atrial fibrillation, seizures, epilepsy, fibromyalgia, cancer, anemia, kidney disease, headaches, Parkinson’s disease, etc.)
2. Past Surgical History / Please list: (Example: Facial or upper airway, tonsillectomy, septoplasty, sinuses, UPPP, etc.)
3. Family Medical History / Please list:
4. Do you have any allergies to medications? If Yes, please list:
5. List of current medications, including over the counter.
6. Do you currently take prescribed or over the counter medications to help you sleep? If Yes, name of medication and dose and how often:
7. Do you use any prescribed stimulants (e.g. Ritalin ,Adderall ,Provigil ,Nuvigil)? If Yes, name of medication and dose and how often:
8. Do you use illicit drugs? Please include recreational or medicinal marijuana, CDB oils.?
9. Are you involved in a substance abuse treatment program?
10. Do you have any blood relatives who suffer from Sleep Apnea, Restless Legs Syndrome, Narcolepsy, Insomnia, Heavy snoring, or Sleep-walking? If Yes, who?