Patient Sleep Survey

Today's Date

Patient Name:

Patient Date of Birth:

Did You Feel Sleepy Today?

Yes

No

Did You Take Any Naps Today?

Yes

No

If Yes, What Time and For How Long Did You Sleep

Have You Had Anything To Drink In The Last 5 Hours That Contained Caffeine?

Yes

No

Have You Had Any Alcohol Today?

Yes

No

Are You Experiencing Any Pain?

Yes

No

If Yes, Please Describe

Is Your Primary Doctor Aware Of This Pain?

Yes

No

N/A

How Many Nights A Week Are You Using CPAP?

How Many Hours A Night Are You Using CPAP?

Are You Having Any Problems Using CPAP?

Yes

No

If Yes, What Problems Are You Having?

Are You Feeling Sleepy During The Daytime?

Yes

No

If Yes, Please Explain: