EnglishEspañol Sleep Profiler Medical History Questionnaire© PRINT IN CAPITAL LETTERS – STAY WITHIN THE BOX SECTION A: Patient Demographics First Name Middle Initial Last Name Weight (Pounds) Age (Years) Gender Male Female Height - FeetHeight - Inches Neck Size (Inches) (Optional) Date of Birth - MonthDate of Birth - DayDate of Birth - Year ID Number (Optional) SECTION B: Medical HistoryHave you been diagnosed or treated for any of the following conditions or have the following symptoms? High Blood PressureYesNo Restless Leg SyndromeYesNo NarcolepsyYesNo Recent Head TraumaYesNo Painful ConditionYesNo Heart DiseaseYesNo Sleep ApneaYesNo DepressionYesNo StrokeYesNo A.M. HeadachesYesNo DiabetesYesNo InsomniaYesNo Anxiety or PTSDYesNo Neurological DisorderYesNo Night SweatsYesNo SECTION C: Epworth Sleepiness ScaleHow likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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 mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)0 = would never doze / 1 = slight chance of dozing / 2 = moderate chance of dozing / 3 = high chance of dozing 1. Sitting and reading 2. Watching TV 3. Sitting inactive in a public place (theater, meeting, etc) 4. As a passenger in a car for an hour without a break 5. Lying down to rest in the afternoon when circumstances permit 6. Sitting and talking to someone 7. Sitting quietly after lunch without alcohol 8. In a car, while stopped for a few minutes in traffic SECTION D: Insomnia SeverityPlease rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s) 1. Difficulty falling asleepNoneMildModerateSevereVery Severe 2. Difficulty staying asleepNoneMildModerateSevereVery Severe 3. Problem waking up too earlyNoneMildModerateSevereVery Severe SECTION E: Sleep Satisfaction and Impact How SATISFIED or DISSATISFIED are you with your CURRENT sleep pattern?Very SatisfiedSatisfiedModerately SatisfiedDissatisfiedVery Dissatisfied How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?Not at all NoticeableA LittleSomewhatMuchVery Much Noticeable How WORRIED / DISTRESSED are you about your current sleep problem?Not at all WorriedA LittleSomewhatMuchVery 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 InterferingA LittleSomewhatMuchVery Much Interfering SECTION F: Substance Use How often during the week do you drink alcoholic beverages in the evening before falling asleep?Never1-2 Times2-3 Times4-5 TimesAlways 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)?NeverRarelySometimesFrequentlyAlmost Always SECTION G: Sleep HabitsFor these questions: Rarely = 0-1 times/week, Sometimes = 1-2 times/wk, Frequently = 3-4 times/wk, Almost Always = 5+ times/wk 1. Do you have problems keeping your legs still at night or need to move them to feel comfortable?NeverRarelySometimesFrequentlyAlmost Always 2. Do you have vivid or troubling nightmares?NeverRarelySometimesFrequentlyAlmost Always 3. On average, in the past month, how often have you snored or been told that you snored?NeverRarelySometimesFrequentlyAlmost Always 4. Do you wake up choking or gasping?NeverRarelySometimesFrequentlyAlmost Always 5. Have you been told that you stop breathing in your sleep or wake up choking or gasping?NeverRarelySometimesFrequentlyAlmost Always 6. How often do you take a prescription medication to help you fall asleep or stay asleep?NeverRarelySometimesFrequentlyAlmost Always 7. How often do you take an 'Over the Counter' medication to help you fall asleep or stay asleep?NeverRarelySometimesFrequentlyAlmost Always SECTION H: 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 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 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 9. Thoughts that you would be better off dead, or of hurting yourself in some way SECTION I: 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 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being too restless so that it is hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen SECTION J: MedicationsDo you routinely take any of the following medications? Ambien (Zolpidem)YesNo RozeremYesNo IntermezzoYesNo Narcotic for PainYesNo Heart DiseaseYesNo AntihistaminesYesNo Lunesta (Eszopiclone)YesNo Sonata (Zaleplon)YesNo Silenor (Doxepin)YesNo High Blood PressureYesNo AntidepressantYesNo Anti-anxiety/tranquilizerYesNo HalcionYesNo RestorilYesNo XanaxYesNo SteroidYesNo Parkinson'sYesNo Stimulant/ADHDYesNo Footer Signature Area Code Phone Number Submit Form