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Sleep Evaluation

Print blank form to fill by hand

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Name :
	*Last Name:	Middle Name:	*First Name:

*Your birthday :

Age:

Sex:

Male Female

Height :

Weight :

*Home Address :					City
	State		Zip		Apt#

*Home Phone :

()--

*Email address:

1.	Do you snore? Yes No Don't know
If You Snore, Please Answere The Following Questions:

2.	Has your weight changed?
	Increased
	Decreased
	No change
3.	Your snoring is .....
	Slightly louder than breathing.
	As loud as talking.
	Louder than talking.
	Very loud.
4.	How often do you snore?
	Almost every day.
	3-4 Times a week.
	1-2 Times a week.
	Never or almost never.
5.	Does your snoring bother other people?
	Yes No
6.	Has anyone noticed that you quit breathing during your sleep?
	Almost every day.
	3-4 Times a week.
	1-2 Times a week.
	Never or almost never.

7.	Are you tired after sleeping?
	Almost every day.
	3-4 Times a week.
	1-2 Times a week.
	Never or almost never.
8.	Are you tired during wake time?
	Almost every day.
	3-4 Times a week.
	1-2 Times a week.
	Never or almost never.
9.	Have you ever nodded off or fallen asleep while driving?
	Yes No
	If yes, how often does it occur?
	Almost every day.
	3-4 Times a week.
	1-2 Times a week.
	Never or almost never.
10.	Do you have high blood pressure? Yes No Don't know

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, compared to just feeling tired. This refers to your usual way of life in recent times. Even if you have not 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

Situation	Chance of dozing
Sitting and reading	0 1 2 3
Watching TV	0 1 2 3
Sitting inactive in a public place (meeting, theater)	0 1 2 3
As a passenger in a car for an hour without a break	0 1 2 3
Lying down to rest in the afternoon when circumstances permit	0 1 2 3
Sitting and talking to someone	0 1 2 3
Sitting quietly after eating lunch without alcohol	0 1 2 3
In a car while stopped for a few minutes in traffic	0 1 2 3
Total points:


*Signature	Date