Patient Sleep Survey | Serene Sleep Center, Flint, MI

Today's Date:

Patient's Name:

Date of birth:

Height:

Weight:

Sex:

Male

Female

Questionnaire filled by:

Phone:

Relationship to Patient:

Name of Primary Care Physician:

Physician's Phone:

Any Current Medical Problem?

Past Medical History:

Previous Surgery(s):

Allergies:

Medications:

How Often Meds are taken:

Last Taken:

Family History

Family History

Family History (check all that apply) :

Please provide details of selected above (relationship to patient):

How Long

Any History of Weight Change:

Any History of Weight Change?

Any history of weight change?

Gain

Loss

Over How Long?

Reason for coming to sleep center?

At what age did this start?

Free Text

Sleep History

How long does it usually take to fall asleep?

Usual bedtime:

Weekday Bedtime:

Weekend Bedtime:

Usual wake up time:

Weekday wake up Time:

Weekend wake up time:

Usual bedtime:

Usual hours of sleep:

Weekday Hours of sleep:

Weekend hours of sleep:

Does he/she wake up at night?

Yes

No

If yes, how often and reason:

Is it hard to wake him/her up in the morning?

Yes

No

Does he/she feel sleepy or tired in the morning?

Yes

No

During sleep, does this patient:

During sleep, does this patient:

During sleep, does this patient do any of the following? (check all that apply):

Snore? If Yes, how loud and how long does it last?

Any abnormal movement during sleep?

Any abnormal movement during sleep?

Any abnormal movement during sleep? (check all that apply):

"growing pain" or unexplained leg pain

"growing pains" that are worse at night

Grinds teeth while asleep

Kicks legs while asleep

Daytme Behavior and other possible problems:

Daytme Behavior and other possible problems:

Does the patient do any of the following during the day (Check all that apply):

Breath through mouth

Wake-up with headaches

Take naps

If patient takes naps, please include how long, and what time this occurs:

Excessive Daytime Sleepiness

Excessive Daytime Sleepiness

Has he/she felt an irresistible urge to take a nap at an odd time, forcing him/her to stop what he/she is doing in order to sleep?

Yes

No

If yes, at what age did this first develop?

Does your child have any sleepiness during the day?

Yes

No

If yes, what time of day?

Has he/she ever found themselves awake in bed able to look around, but unable to move for a short period?

Yes

No

Has he/she ever become suddenly weak in the legs or anywhere else after laughing, being angry, or being surprised by something?

Yes

No

Has he/she ever sensed that he/she was dreaming (seeing or hearing sounds) while still awake?

Yes

No

Does he/she drink caffeinated beverages on a typical day?

Yes

No

If yes, how many cups per day?

When

Any smoking?

Yes

No

Drug abuse?

Yes

No

Alcohol abuse?

Yes

No

Bed Wetting

Bed Wetting: (Answer these questions ONLY if your child is over the age of 5 years.)

Frequent urination

Yes

No

Pain in urination

Yes

No

History of bladder infection

Yes

No

Constipation

Yes

No

Recent Weight Loss

Yes

No

Allergies

Yes

No

Bed Wetting During the Day

Yes

No

Bed Wetting During the Night

Yes

No

Back Problems

Yes

No

Any history of sleep problems

Nightmares

Sleep Terrors

Sleep Walking

Snoring

Family History of Bed Wetting

Yes

No

Bed Wetting Since Birth

Yes

No

If no, what age restarted

Hyper Activity/Inattention

Hyper Activity/Inattention:

Difficulty sustaining attention, starts something new before finishing task

Rarely

Sometimes

Often

Always

Does not seem to follow through with instructions and fails to finish school work

Rarely

Sometimes

Often

Always

Runs about or climbs excessively in situations where it is inappropriate

Rarely

Sometimes

Often

Always

Teacher Observation:

Hyperactivity?

Yes

No

Short attention span?

Yes

No

Napping?

Yes

No

Failing Grades?

Depression/Insomnia:

Depression/Insomnia:

Difficulty initiating sleep?

Yes

No

Waking up frequently from sleep?

Yes

No

Waking up early in the morning?

Yes

No

Feeling fatigue during the day?

Yes

No

Inability to concentrate or remember things?

Yes

No

Decreased or loss of appetite?

Rarely

Sometimes

Often

Always

Feels depressed, sad or irritable?

Rarely

Sometimes

Option 3

Always

Feelings of guilt, hopelessness?

Rarely

Sometimes

Often

Always

Other Comments:

Epworth Sleepiness Scale - Children

Epworth Sleepiness Scale - Children

Free Text

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 have not done some of these things recently, think about how they would have affected you. Use the following scale to choose themost appropriate numbeer for each situation.

scale

0 = would never doze or sleep

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Sitting and reading

0

1

2

3

Sitting inactive in a public place (for example, a movie theater or classroom)

0

1

2

3

Watching TV

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 lunch

0

1

2

3

Doing homework or taking a test

0

1

2

3

Total (add up each score):

Pediatric Questionnaire

Contact Us

Serene Sleep Center

1125 S. Linden Road, Suite 270

Flint, MI 48532

Phone: 810-600-7000

Fax: 810-422-9131