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Sleep Study Questionnaire

Name

E-Mail

Phone

Age

Height

Weight

Gender

Have you ever had an evaluation at a Sleep Center?

Yes
No

Sleep Center Name

Location

Sleep Study Details

CPAP (Continuous Positive Airway Pressure) Intolerance

If you have attempted treatment with a CPAP device, but could not tolerate it, please fill in this section.

mask leaks
I was unable to get the mask to fit properly
discomfort caused by the straps and headgear
disturbed or interrupted sleep caused by the presence of the device
noise from the device disturbing my sleep and/or bed partner's sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
pressure on the upper lip causing tooth replacement problems
a latex allergy
claustrophobic associations
an unconscious need to remove the CPAP apparatus at night

Other

Other Therapy Attempts

What other therapies have you had for breathing disorders? (Weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)

Do You Snore?

If you snore...

How loud do you snore?	During your waketime, do you feel tired, or not up to par?
How often do you snore?	Have you ever nodded off or fallen asleep while driving a vehicle?
Does your snoring bother other people?	If yes, how often does it occur?
Has anyone noticed that you quit breathing during your sleep?	Do you have high blood pressure?
How often do you feel tired or fatigued after you sleep?

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Sitting and reading	Lying down to rest in the afternoon when circumstances permit
Sitting in a public place (e.g.: theatre, meeting or church)	Sitting and talking to someone
As a passenger in a car for an hour without a break	In a car, while stopped for a few minutes in traffic
Watching TV