Makesleepeasy.com
Sleep History Form
First Name *
Your answer
Last Name *
Your answer
Date of birth *
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DD
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Gender at birth *
Height in inches *
Your answer
Weight in pounds *
Your answer
Email *
Your answer
Complaint *
What sleep problems are you experiencing? Check all that apply.
Required
Duration *
How long have you had these probelms?
Previous study *
Have you ever had a sleep study before?
Bed partner *
Who else sleeps in the bed with you?
Your answer
Sleep environment *
Wha sources of light or noise do you have powered on and in the room when you are sleeping? (check all that apply)
Required
Bedtime routine *
What is your bedtime routine (things you usually do before getting into bed)?
Your answer
Week day bedtime *
What is your average bedtime during the week or on days you work?
Time
:
Weekend bedtime *
What is your average bed time on the weekend or before days off?
Time
:
Week day awakening *
On average, what time do you get out of bed for the day during the week or on days you work?
Time
:
Weekend awakening *
On average, what time do you get out of bed for the day on weekends or days off?
Time
:
Arousals *
On average, how many times a night do you remember waking up between falling asleep the first time and getting out of bed for the day?
Your answer
Naps *
How many days out of a typical 7 day week do you nap - either intentionally or unintentionally?
Your answer
Nap length
On average, how long are the naps?
Restless legs *
How many nights a week do uncomfortable sensations in your legs prevent you from falling asleep or staying asleep?
Sleepwalking *
How often in the past year have you had episodes of sleep walking?
PMH *
What chronic medical problems do you have?
Required
Surgeries *
What surgeries have you had in the past?
Your answer
Medications *
Please list the medications you take and the dosages
Your answer
Caffeine *
On average, how many drinks with caffeine do you have a day? (1 drink = 8 ounces of coffee, tea, sodas, or energy drinks with caffeine.)
Your answer
Smoking years *
How many years did you smoke cigarettes?
Your answer
Cigarettes per day
On average, how many cigarettes a day were you smoking during this time?
Your answer
Alcohol *
On average how many days of the week do you have at least one drink of alcohol including wine, beer or spirits?
Your answer
Substance abuse *
Do you use other drugs such as marijuana, cocaine, heroin, LSD, or crystal meth?
Family history *
What diseases run in your family?
Your answer
Epworth *
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 dose
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (theatre or meeting)
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 a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
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