Advantage Sleep Centers

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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?

Yes

Clear selection

Select the items below that you are experiencing or have been diagnosed with.

I EXPERIENCE, HAVE EXPERIENCED, OR HAVE BEEN DIAGNOSED WITH....

witnessed choking or gasping

mouth breathing

shortness of breath

nightly coughing

palpitations

morning headaches

bed wetting

frequent awakenings at night to urinate

concentration difficulty

restless legs

sleep walking

sleep talking

vivid dreams or nightmares

sleep paralysis

blood sugar disorder

lung disease

arthritis

extreme tossing and turning

urge to move legs or arms at during sleep

acid reflux

hypertension

heart attack

congestive heart failure

thyroid disease

teeth grinding

anxiety

muscle weakness triggered by emotions

previously diagnosed with sleep apnea

currently using PAP therapy

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

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?

Yes

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