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Liberty sleep associates, llc

418 FOLLY RD. SUITE D TEL: 843-795-5553 CHARLESTON, SC 29412 FAX: 843-795-2262 LIBERTY SLEEP ASSOCIATES, LLC
SLEEP DISORDERS CENTER
Patient Name: _________________________________ Sex: ________ Age: _______ Date:_________ Occupation: ________________________________ Usual Work Hours/Days: _____________________ Family Physician (PCP): __________________ Ht ________Wt _________ Neck Size: _____________ What was your weight one year ago?_______________
Marital status: (circle one) Single Married Divorced Widowed
____________________________________________________________________________________
Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas.
My Main Sleep Complaint(s) Is:
__________trouble sleeping at night For how many months/years? _____________________________________
__________being sleepy all day For how many months/years? _____________________________________
__________snoring
For how many months/years? _____________________________________
__________unwanted behaviors during sleep, explain________________________________________________________
__________Other, explain _____________________________________________________________________________
Sleep Pattern
Typical amount of time it takes to fall asleep: Typical number of awakenings per night: Typical amount of time to fall back asleep How do you usually awaken? (i.e. alarm clock): 418 FOLLY RD. SUITE D TEL: 843-795-5553 CHARLESTON, SC 29412 FAX: 843-795-2262 LIBERTY SLEEP ASSOCIATES, LLC
SLEEP DISORDERS CENTER
Please check all of the following statements that are true about your sleep:
Sleep Habits
______I usually watch TV or read in bed prior to sleep
_____ I frequently travel across 2 or more time zones
_____ I drink alcohol prior to bedtime
_____ I smoke prior to bedtime or when I awaken during the night
_____ I eat a snack at bedtime
_____ I eat if I awaken during the night
_____ I typically awaken to urinate during sleep
_____ I have trouble falling asleep
_____ I awaken frequently during the night
_____ I am unable to return to sleep easily if I awaken during the night
_____ Thoughts start racing through my mind when I try to fall asleep
_____ I awaken early in the morning, still tired but unable to return to sleep
_____ I have nightmares as an adult
_____ I experience a creeping-crawling or tingling sensation in my legs when I try to fall asleep
_____ I sweat a great deal during sleep
_____ I cannot sleep on my back
Breathing
_____ I have been told that I stop breathing while asleep
_____ I awaken at night choking, smothering or gasping for air
_____ I have been told that I snore
_____ I have been told that I snore only when sleeping on my back
_____ I have been awakened by my own snoring
Restlessness

_____ I am a restless sleeper
_____ I kick or jerk my legs and/or arms during sleep
_____ I experience restlessness, tingling or crawling in my arms or legs
_____ I experience an inability to keep my legs still prior to falling asleep
_____ I talk in my sleep as an adult
_____ I have sleep walked as an adult
_____ I grind my teeth in my sleep
418 FOLLY RD. SUITE D TEL: 843-795-5553 CHARLESTON, SC 29412 FAX: 843-795-2262 LIBERTY SLEEP ASSOCIATES, LLC
SLEEP DISORDERS CENTER

Daytime Sleepiness
_____ I take daytime naps
_____ I have a tendency to fall asleep during the day
_____ I have experienced lapses in time or blackouts
_____ I have fallen asleep while driving
_____ I have had auto accidents as a result of falling asleep while driving
_____ I fall asleep while watching TV
_____ I fall asleep during conversations
_____ I fall asleep in sedentary situations
_____ I performed poorly in school because of sleepiness
_____ I have had injuries as the result of sleepiness
_____ I have experience sudden muscle weakness in response to emotions such as laughter, anger or
_____ I have experienced an inability to move while falling asleep or when waking up
_____ I have experienced hallucinations or dreamlike images or sounds when falling asleep or waking up
_____ I drink caffeinated beverages during the day _____cups/bottles/cans per day
Habits
Do you smoke?


Do you drink alcohol?

Social History

_____ I sleep alone
_____ I share a bed with someone
_____ I share a bedroom, but have separate beds
_____ I share a dwelling, but have separate bedrooms

Employment Status:
ٱ Employed
_____ My job requires me to drive a vehicle _____ I work with dangerous equipment or substances _____ I am a shift worker on rotating shifts _____ I am a permanent or long term third shift worker _____ I am currently a student 418 FOLLY RD. SUITE D TEL: 843-795-5553 CHARLESTON, SC 29412 FAX: 843-795-2262 LIBERTY SLEEP ASSOCIATES, LLC
SLEEP DISORDERS CENTER

Please put a check next to all you have taken or are currently taking :

Klonopin
Wellbutrin
Ambien CR
Neurotin
Percocet
Liopresal
Tylenol PM
Concerta
Morphine
Restoril
Adderall
Trazodone
Oxycotin
Provigil
Methadone
Benadryl
Darvocet
Recreational Drugs : ____________________________

Please list any other medications you are currently taking:______________________________
________________________________________________________________________________
Allergies:
________________________________________________________________________
Past Sleep Evaluation and Treatment
_____ I have had a previous sleep disorder evaluation
_____ I have had previous overnight sleep studies
_____ I have had daytime nap studies
_____ I have been prescribed a CPAP or bi-level machine for home use
_____ I have had surgical treatment for a sleep disorder
_____ I have previously been prescribed medication for a sleep disorder
_____
I have been previously treated for a sleep disorder
Past Medical History
_____ Hypertension (high blood Pressure) _____ Heart Disease
_____ Back or joint problems (arthritis) 418 FOLLY RD. SUITE D TEL: 843-795-5553 CHARLESTON, SC 29412 FAX: 843-795-2262 LIBERTY SLEEP ASSOCIATES, LLC
SLEEP DISORDERS CENTER
Answer Key 1 – Never
Using the above Answer Key, please circle the number that best applies to your life over the past 6 months.

I have trouble getting to sleep
At bedtime, thoughts race through my mind When falling asleep, I feel paralyzed (unable to move) When falling asleep, I have "restless legs" (a feeling of crawling, Aching, or inability to keep legs still) I awake suddenly gasping for breath, unable to breathe I have trouble with my nose blocking up when I am going to sleep. I have a lot of nightmares (frightening dreams) I have dream-like images (hallucinations) when I awaken in the Morning even though I know I am not asleep I have slept for several days at a time, or at least I have been Overwhelmingly sleepy for that long I am very sleepy during the day and I struggle to stay awake I now have trouble doing my job because of sleepiness and fatigue I often have to let someone else drive the car because I am too Sleepy to do it I am often unable to move (paralyzed) when I am waking up in I have pets (cats and or dogs) that sleep in the bed with me at night. I get sudden muscular weakness (or even a brief period of paralysis, Being unable to move) when laughing, angry, or in situations of My children will sleep in bed with me or crawl in bed with me at night. My snoring or my breathing problem is much worse if I sleep on

Source: http://www.libertysleep.net/Sleep%20History%20and%20Medical%20History.pdf

Microsoft word - address for manjimup atga 2011.doc

Good morning Ladies and Gentleman. I thought that I was going to be making comments which be unpopular, however Graham Duell, Simon McCall and Brad Plunkett have all beaten me to the punch. Nevertheless some of you will regard my comments as negative, others will see them as honest and constructive. What I am about to say is based on facts and experience and will be a summary from a growers pers

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Psychoneuroendocrinology (2004) 29, 1341–1344Effects of PhD examination stress onallopregnanolone and cortisol plasma levels andperipheral benzodiazepine receptor densityHal A. Droogleever Fortuyna, Frank van Broekhovena,*, Paul N. Spanb,Torbjo¨mc, Frans G. Zitmana,1, Robbert J. VerkesaaUnit for Clinical Psychopharmacology and Neuropsychiatry, 331 Department of Psychiatry,University Medical

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