W 11 Sleep Questionaire
W 11 Sleep Questionaire
W 11 Sleep Questionaire
55 FRID STREET, UNIT 7 HAMILTON, ONTARIO L8P4M3 PHONE: (905) 529-2259 FAX: (905) 529-2262
282 LINWELL ROAD, UNIT 118 ST. CATHARINES, ONTARIO L2N 6N5 PHONE: (905) 529-2259
700 CORONATION BLVD., CAMBRIDGE, ONTARIO N1R3G2 PHONE: (519) 740-4972
EMAIL: reception@sleep-clinic.ca
WEBSITE: www.sleep-clinic.ca
SLEEP QUESTIONNAIRE
PLEASE PRINT CLEARLY
Name:
Date:
Phone Number:
Cell:
Email address:
Date of Birth:
Occupation:
Height:
Weight:
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.
Use the following scale to choose the most appropriate number for each situation.
0 = would never doze
2 = moderate chance of dozing
1 = slight chance of dozing
3 = high chance of dozing
CHANCE OF DOZING / SLEEPING
SITUATION
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
TOTAL:
MEDICATIONS:
3
3
3
3
3
3
3
3
Please list the medications that you are taking and dosage if you know it.
1.______________________________________
2.______________________________________
3. _____________________________________
4. _____________________________________
5. _____________________________________
6. _________________________________________
7._________________________________________
8. _________________________________________
9. _________________________________________
10. ________________________________________
Do you take any medications to help you sleep including over the counter preparations?
Yes No
Yes No
Yes No
Quit? When?
(total #)
#/day:
30 60 minutes
Yes No
In the past week, how many hours did you sleep, per night, on average?
Do you routinely sleep with the TV on, or is there other noise that disturbs your sleep?
Do you work shifts or irregular hours?
Yes No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Explain:
Do you snore?
If yes, on a scale of 1 10 (10 being the loudest) How loud do you snore?
Yes
Yes
Yes
Yes
Yes
No Yes
Yes No
Yes No
How much?
How much?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes
Yes
Yes
Yes
No
No
No
No
Yes No
Do you find that your mind is not working as quickly or that you are more forgetful?
Have other people told you that you are more irritable or short tempered?
Have you had trouble having sex recently?
Yes No
Yes No
Yes No
Yes No
Yes
Yes
Yes
Yes
No
No
No
No
Yes No
Yes No
Yes No
Yes No
Asthma
Depression
Gastroesophageal Reflux Disease (GERD)
Yes No
Yes No
Yes No
Diabetes
Chronic Obstructive Pulmonary Disease
Yes No
Where:
Where:
Yes No
Yes No
PARENTS
Mother
Father
Have any family members been diagnosed with a sleep problem or other significant health problems?
Please explain;
HOSPITAL ADMISSIONS:
Please list all times that you have been in hospital, starting with the most recent.
Year
PHYSICIANS
Please list the names of ALL physicians who are currently taking care of your health needs.
Name
Specialty
ILLNESSES OF NOTE
Please list any illness of note and years if applicable.
Illness
Date Diagnosed
Ongoing?
Yes No
Yes No
Yes No
Yes No
Yes No
Why do think your doctor has sent you to the Sleep Disorders Clinic?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Thank you for taking the time to fill ion this questionnaire. Please bring it with you to your sleep study.
All patients information is kept strictly confidential except where required to be divulged by law.