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
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
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