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D42-8101-2+Rev+5+Sleep+Profiler+Meds+Questionnaire

Name:

Date of Birth;

Weight:

Hight:

Neck size :

ID number (optional) :

High Blood Pressure

Yes

Restless Leg Syndrome

Yes

Narcolepsy

Yes

Recent Head Trauma

Yes

Painful Condition

Yes

Heart Disease

Yes

Sleep Apnea

Yes

Depression

Yes

Stroke

Yes

A.M. Headaches

Yes

Diabetes

Yes

Insomnia

Yes

Anxiety or PTSD

Yes

Neurological Disorder

Yes

Night Sweats

Yes

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t 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

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

Sitting and reading

Watching TV

Sittinginactive in a public place (theater, meeting, etc)

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 lunch without alcohol

In a car, while stopped for a few minutes in traffic

Please rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s)

Difficulty falling asleep

Difficulty staying asleep

Problem waking up too early

How SATISFIED or DISSATISFIED are you with your CURRENT sleep pattern?

How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

How WORRIED / DISTRESSED are you about your current sleep problem?

To what extent do you consider your sleep problem to INTERFERE with your CURRENTfunctioning (e.g. Daytime fatigue, ability to function at work/ daily chores, concentration,memory, mood, etc.)?

How often during the week do you drink alcoholic beverages in the evening before falling asleep?

Do you drink more than one beverage with caffeine in the afternoon or evening (i.e., coffee,tea, energy or soft drinks)?

For these questions:

Rarely= 0-1times/week

Sometimes=1-2 times/wk

Frequently= 3-4 time /wk

Almost Always= 5+ times/wk

For these questions:

Rarely= 0-1times/week

Sometimes=1-2 times/wk

Frequently= 3-4 time /wk

Almost Always= 5+ times/wk

Do you have problems keeping your legs still at night or need to move them to feel comfortable?

Never

Rarely

Sometimes

Frequently

Almost Always

Do you have vivid or troubling nightmares?

Never

Rarely

Sometimes

Frequently

Almost Always

On average,in the past month, how often have you snored or been told that you snored?

Never

Rarely

Sometimes

Frequently

Almost Always

Do you wake up choking or gasping?

Never

Rarely

Sometimes

Frequently

Almost Always

Have you been told that you stop breathing in your sleep or wake up choking or gasping?

Never

Rarely

Sometimes

Frequently

Almost Always

How often do you take a prescription medication to help you fall asleepor stay asleep?

Never

Rarely

Sometimes

Frequently

Almost Always

How often do you take an ‘Over the Counter’ medication to help you fall asleep or stay asleep?

Never

Rarely

Sometimes

Frequently

Almost Always

Patient Health Questionnaire (PHQ-9): Over the last 2 weeks, how often have you been bothered by any ofthe following problems?

0 = not at all

1 = several days

2 = more than half the days

3 = nearly every day

Patient Health Questionnaire (PHQ-9): Over the last 2 weeks, how often have you been bothered by any ofthe following problems?

0 = not at all

1 = several days

2 = more than half the days

3 = nearly every day

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself –or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself in some way

Generalized Anxiety Disorders (GAD-7): Over the last 2 weeks, how often have you been bothered by any of the following problems?

0 = not at all

1 = several days

2 = more than half the days

3 = nearly every day

Generalized Anxiety Disorders (GAD-7): Over the last 2 weeks, how often have you been bothered by any of the following problems?

0 = not at all

1 = several days

2 = more than half the days

3 = nearly every day

Not being able to stop or control worrying

Feeling afraid as if something awful might happen

Worrying too much about different things

Being too restless so that it is hard to sit still

Becoming easily annoyed or irritable

Feeling nervous, anxious, or on edge

Trouble relaxing

Do you routinely take any of the following medications?

Ambien (Zolpidem)

Lunesta (Eszopiclone)

Halcion

Rozerem

Sonata (Zaleplon)

Restoril

Intermezzo

Silenor (Doxepin)

Narcotic for Pain

High Blood Pressure

Antidepressant

Anti-anxiety/tranquilizer

Xanax

Steroid

Parkinson’s

Stimulant/ADHD

Email:

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