1. What is your height? _______feet _______ inches
2. What is your weight? ___________pounds
3. Are you a shift worker? YES NO IF so, what shift? ____________
4. What time do you go to bed on WEEKDAYS? ____________ AM or PM
5. What time do you wake up on WEEKDAYS? ____________ AM or PM
6. What time do you go to bed on WEEKENDS? ____________ AM or PM
7. What time do you wake up on WEEKENDS? ____________ AM or PM
8. Do you nap during the day? YES NO A. How often do you nap? _____________________ B. How long are your naps? _____________________minutes C. Do you awaken refreshed? YES NO
9. Do you fall asleep while watching TV after work? YES NO
10. Are you a current/former smoker? CURRENT FORMER NON SMOKER A. Type? (cigars, pipes, cigarettes) ____________ B. How long have you smoked? ____________ years C. How many packs a day do you smoke? ____________ D. If former, when did you quit? ___________
11. Do you drink alcohol? YES NO A. How much do you consume on a daily basis? _______________________
12. How many caffeinated beverages do you drink per day? a. Coffee ______________ b. Tea ________________ c. Soft drink ___________
13. Do you take any recreational drugs such as marijuana, cocaine, speed, meth, LSD, heroine? YES NO A. Type? _________________________ B. How often?____________________ C. If not currently, have you done so in the past? YES NO
2
14. What problems are you having that made you seek our help? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
15. How does this problem affect your life? _______________________________________________________________________________ _______________________________________________________________________________ __________________________________________________________________
Please list all medications you currently take.
How long have Name of Medication Dosage/frequency you been taking this Reason
16. Do you have any food or drug allergies? YES NO A. If yes, please list. _________________________________________________________
17. Have you had any hospitalizations or surgeries? YES NO A. If yes, please list type and dates.__________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Please check the box for each problem you CURRENTLY HAVE.
Loud snoring Crawling feelings in legs when trying to sleep Morning dry mouth Frequent awakenings at night Feeling paralyzed or unable to move when falling asleep Sleep talking Choking for breath at night Dream-like images just after waking up Sleepwalking Gasping during sleep Sudden muscular weakness during strongly Nightmares Awaken un-refreshed emotional times Leg-kicking Sweating a lot at night Trouble falling asleep at night during sleep Restlessness during sleep Waking too early in the morning Bedwetting Morning headaches Tongue biting in sleep Acting out dreams Doing things that make no sense, Uncontrollable daytime sleep attacks Falling asleep at work/school such as writing nonsense or mixing Falling asleep unexpectedly Pain interfering with sleep gravy with chocolate Falling asleep with driving Where is the pain? _______________________ Anxiety Paranoia Mood swings Panic attacks Mania Anger Hearing voices Decreased appetite Irritability Depression Difficulty concentrating h/o sexual abuse Difficulty completing tasks Increased appetite h/o physical abuse
3
Please check any of the following health problems you have now or have had in the past.
Diabetes Now Past Anemia Now Past High Blood Pressure Now Past Peptic Ulcers Now Past Stroke Now Past Acid Reflux (Heartburn) Now Past Heart Disease of CHF Now Past Kidney Disease Now Past Heart Attack Now Past Thyroid Disease Now Past Angina Now Past Arthritis Now Past Emphysema Now Past Back Pain Now Past Asthma Now Past Head Trauma Now Past Tuberculosis Now Past Severe Headaches Now Past Other Lung Disease Now Past Epilepsy (Seizures) Now Past Nasal Allergies Now Past Passing Out Spells (Fainting) Now Past Runny or Blocked Nose Now Past Depression Now Past Hormonal Problems Now Past Anxiety Disorder Now Past Urological Problems Now Past Problems with Alcohol Now Past Liver Disease Now Past Problems with Drugs Now Past
How would you rate your current health? VERY POOR POOR AVERAGE GOOD VERY GOOD
Please give us important details about your medical condition. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Family Information
1. Is your father living? YES NO If yes, how old is he? _________
If no, at what age did he die? _________ What caused his death? _________________
2. Is your mother living? YES NO If yes, how old is she? _________
If no, at what age did she die? _________ What caused her death? _________________
3. Please list your brothers and sisters below with their age they are now (if living) or the age they were (at death) and list the cause of death.
Name Age Now Age at death Reason for death
4
To the best of your knowledge, please check below all that apply.
Father Mother Brother Sister Child Other Goiter
Diabetes
Obesity
Depression
Bipolar disorder (manic depression)
Heart attack
Stroke
Angina
Problems with Alcohol
Problems with Drugs
Cancer
Hormonal Problems
Schizophrenia
Depression
Nervous Trouble
High Blood Pressure
Epilepsy
Kidney Disease
5
EPWORTH SLEEPINESS SCALE
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, try to work out how they would have affected you. Please check one box per line.
0= would never dose 1= slight chance of dosing 2= moderate chance of dosing 3= high chance of dosing
Situation Chance of Dozing off
Sitting and reading 0 1 2 3
Watching TV 0 1 2 3
Sitting, inactive in a public place (theater or meeting) 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 without alcohol 0 1 2 3
In a car, while stopped for a few minutes in traffic 0 1 2 3