Advantage Sleep Centers
For any questions, please call: 856-772-1119
Sleep History Questionnaire
Please complete this form in full to expedite scheduling your sleep study.
Study Number:
For HIPAA compliance and your protection, this number is provided after you request your paperwork.
What MEDICATIONS are you currently taking?
Please list your current medications.
When did your sleep problem begin and what are you experiencing?
Describe your sleep problem.
Have you ever had a sleep study performed? Where?
Prior sleep testing.
What are your work hours?
Describe work schedule.
Sleep Schedule
This section will ask you questions about your sleep habits.
What are your sleep times during the week?
Describe what time you go to sleep during the week.
What time do you wake up during the week?
Describe what time you wake up during the week.
How many hours do you sleep each night during the week?
Describe how many hours you get, on average, during the week.
What are your sleep times on the weekend?
Describe what time you go to sleep during the weekend.
What time do you wake up during the weekend?
Describe what time you wake up during the weekend.
How many hours do you sleep each night during the weekend?
Describe how many hours you get, on average, during the weekend.
Beverage Consumption
This section will ask you questions regarding what you drink on any given night.
How much alcohol do you consume per night? What time do you consume it?
Describe your alcohol consumption and time of day it is consumed.
How much coffee, soda, or other caffeinated beverages do you consume? What time do you consume it?
Describe your caffeine intake and the time that it is consumed.
Do you smoke?
Describe your smoking habits.
Are you able to lie flat?
Select the items below that you are experiencing or have been diagnosed with.
I EXPERIENCE, HAVE EXPERIENCED, OR HAVE BEEN DIAGNOSED WITH....
Epworth Questionnaire *
This questionnaire refers to how likely you are to doze off or fall asleep in the following situations. 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
1
2
3
Sitting and reading
Sitting inactive in a public place
As a passenger in a car
Lying down to rest in afternoon
Sitting and talking to someone
Sitting quietly after a lunch
In a car while stopped for a few minutes
Are you currently using APAP, CPAP, or BPAP?
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