EnglishEspañol Sleep Profiler Medical History Questionnaire© Rev 7 (D42-8101-2) Your form has been submitted to headacheMD® Houston. Return to Home Patient Demographics First Name Middle Initial Last Name Weight Pounds Kilograms Age in Years Gender Male Female Height Feet / Inches Centimeters Feet Inches Centimeters Neck Size (optional) Inches Centimeters Date of Birth Month Day Year ID Number (optional) Medical Conditions Diagnosed or Treated Have you been diagnosed or treated for any of the following conditions? High Blood Pressure Yes No Heart Disease Yes No Restless Leg Syndrome Yes No REM Sleep Behavior Dis. Yes No Hypersomnia/Narcolepsy Yes No Sleep Apnea Yes No Insomnia Yes No Depression Yes No Stroke Yes No Diabetes Yes No Anxiety or PTSD Yes No Parkinson's Disease Yes No Cognitive Impairment Yes No Dementia Yes No Other Neuro Disorder Yes No Epworth Sleepiness Scale — / 24 How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? 0 = would never doze 1 = slight chance 2 = moderate chance 3 = high chance of dozing 1. Sitting and reading 0 1 2 3 2. Watching TV 0 1 2 3 3. Sitting inactive in a public place (theater, meeting, etc) 0 1 2 3 4. As a passenger in a car for an hour without a break 0 1 2 3 5. Lying down to rest in the afternoon when circumstances permit 0 1 2 3 6. Sitting and talking to someone 0 1 2 3 7. Sitting quietly after lunch without alcohol 0 1 2 3 8. In a car, while stopped for a few minutes in traffic 0 1 2 3 Insomnia Severity Index (ISI) — / 28 Please rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s) 1. Difficulty falling asleep None Mild Moderate Severe Very Severe 2. Difficulty staying asleep None Mild Moderate Severe Very Severe 3. Problem waking up too early None Mild Moderate Severe Very Severe How SATISFIED or DISSATISFIED are you with your CURRENT sleep pattern? Very Satisfied Satisfied Moderately Satisfied Dissatisfied Very Dissatisfied How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life? Not at all Noticeable A Little Somewhat Much Very Much Noticeable How WORRIED / DISTRESSED are you about your current sleep problem? Not at all Worried A Little Somewhat Much Very Much Worried To what extent do you consider your sleep problem to INTERFERE with your CURRENT functioning (e.g. daytime fatigue, ability to function at work / daily chores, concentration, memory, mood, etc.)? Not at all Interfering A Little Somewhat Much Very Much Interfering Substance Use How often during the week do you drink alcoholic beverages in the evening before falling asleep? Never 1-2 Times 2-3 Times 4-5 Times Always 6-7 Times Do you drink more than one beverage with caffeine in the afternoon or evening (i.e., coffee, tea, energy or soft drinks)? Never Rarely Sometimes Frequently Almost Always Please continue to Side 2 For these questions: Rarely = 0-1 times/week Sometimes = 1-2 times/wk Frequently = 3-4 times/wk Almost Always = 5+ times/wk Sleep Behavior Questions 1. Do you have problems keeping your legs still at night or need to move them to feel comfortable? Never Rarely Sometimes Frequently Almost Always 2. Have you been told that you “act out your dreams” while sleeping? (punching or flailing arms, shouting or screaming) Never Rarely Sometimes Frequently Almost Always 3. On average, in the past month, how often have you snored or been told that you snored? Never Rarely Sometimes Frequently Almost Always 4. Do you wake up choking or gasping? Never Rarely Sometimes Frequently Almost Always 5. Have you been told that you stop breathing in your sleep or wake up choking or gasping? Never Rarely Sometimes Frequently Almost Always 6. How often do you take a prescription medication to help you fall asleep or stay asleep? Never Rarely Sometimes Frequently Almost Always 7. How often do you take an “Over the Counter” medication, THC, or CBD to help you fall asleep or stay asleep? Never Rarely Sometimes Frequently Almost Always Patient Health Questionnaire (PHQ-9) — / 27 Patient Health Questionnaire (PHQ-9): Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 = not at all 1 = several days 2 = more than half the days 3 = nearly every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3 If you are having thoughts of harming yourself, please speak with your provider or call 988 (Suicide and Crisis Lifeline) immediately. Generalized Anxiety Disorders (GAD-7) — / 21 Generalized Anxiety Disorders (GAD-7): Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 = not at all 1 = several days 2 = more than half the days 3 = nearly every day 1. Feeling nervous, anxious, or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being too restless so that it is hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 1 2 3 7. Feeling afraid as if something awful might happen 0 1 2 3 Medications Currently Prescribed Do you routinely take any of the following medications? Intermezzo/Ambien Yes No Other Z-drug sleep aid Yes No Lunesta (Eszopiclone) Yes No Insomnia med-other Yes No High Blood Pressure Yes No Heart Disease Yes No Orexin receptor antagonist Yes No Clonazepam Yes No Xanax/other benzodiazepine Yes No SSRI, SNRI or NDRI Yes No Any other antidepressant Yes No Parkinson's drug/L-DOPA Yes No Gabapentin Yes No AChE inhibitor Yes No Memantine Yes No Anti-amyloid Yes No Narcotic-opioid Yes No Anti-psychotic Yes No Optional Clinical Fields OPTIONAL — clinic use MMSE (optional) MOCA (optional) NDD (optional) Diagnostic Category (optional) Neuropsych Assessment (optional) Diagnosis (optional) Alzheimers Lewy body MCI Parkinsons Vascular Other Amnestic Non-amnestic Other Contact (optional) Email (optional, for a copy) Phone (optional) Your form was not submitted successfully. Please try again. If this problem continues, call us at 713-426-3337 or email info@hmdhou.com. Try Again Submit Form