Email ID

Contact NO.

It is important for you to be accurate in answering the following questions.  The purpose of this questionnaire is to get a total picture of your background and the nature of your present problem. Please complete these questions as thoroughly as you can.  This information will be held in the STRICTEST CONFIDENCE.

1. In the space provided below, please describe your main problem(s) in your own    words, Including when and how this began and what treatments you have     received for this in the past.

2. Has it been a continuous or intermittent problem?
    almost every night
    for periods of at least one week

3. How long has this problem bothered you?
    longer than 2 years
    within the last 3 months
    1 to 2 years
    within the last month
    several months

4. On the scale below, please estimate the severity of your problem:
    mildly upsetting
    extremely severe
    moderately severe

5. How strongly do you want help with your problem?
    very much
    could do without it

6. How do you describe your sleep problem? Check all that apply to you.
    difficulty falling asleep
    excessive daytime sleepiness
    wake up during the night
    difficulty awakening
    wake up early in the morning

7. Do any other members of your family have sleep problems?
    Please explain:

8. Check any of the following that apply to you:
    I have been told that I snore
    I often feel sad or depressed
    I have been told I hold my breath while I sleep
    I have trouble concentrating at work or school
    I have high blood pressure
    I have fallen asleep while driving
    I have been told by friends and family that I’m often grumpy are irritable
    I have experienced vivid dreamlike scenes upon falling asleep or awakening
    I sweat excessively during the night
    I have fallen asleep during a social setting such as the movies or parties
    I have noticed my heart pounding or beating irregularly during the night
    I have dreams soon after falling asleep or during naps
    I have “Sleep Attacks” during the day no matter how hard I try to stay awake
    I suddenly wake up gasping for breath
    I have episodes of feeling paralyzed during my sleep
    I am overweight
    I wake up at night with acid/sour taste in their stomach
    I seem to be losing my sex drive
    I wake up at night coughing or wheezing
    I often feel sleepy and struggle to stay alert
    I wake up suddenly during the night feeling like I’m choking
    I frequently wake with a dry mouth or sore throat
    I experience muscle tension in my legs at times other than exercising
    I have difficulty falling asleep
   I have noticed (or other have commented) that parts of my body jerk during          sleep
    I have thoughts through my mind preventing my from falling asleep
    I have been told that I kick my legs during sleep
    I wake up and can’t go back to sleep
   I experience an aching or crawling sensation in my legs while trying to go to          sleep
    I worry about things and have trouble relaxing
    I experience leg pain or cramps at night
    I wake up earlier in the morning than I would like
   I occasionally can’t keep my legs still at night: I have to move them to feel          comfortable
    I lie awake for ½ hour or more before falling asleep
    I have a history of stroke or TIA’s
   I have a history of Coronary artery disease, heart attack, cardiac surgery or          congestive heart failure
    I am currently on CPAP/BILEVEL
    I am on oxygen
    I have asthma
    I have had surgeries for snoring or sleep apnea

9. Is your present work situation satisfactory? 

10. Does your sleep problem disturb your sex life?(Provide information about any significant relationship)

11.Is your present social life satisfactory? Does your sleep problem require you to cut back on social activity? 

12. What is your personal interpretation as to why you have your particular sleep/wake problem?




Contact No.  

1. How many hours of sleep do you usually get per night?    

2. What time do you usually go to bed on WEEKDAYS?  WEEKENDS? 

3. How long does it take you to fall asleep?   

4. How many times do you typically wake up at night?  

5. What time do you usually awaken in the morning on

6. On average, how long do you stay in bed after waking up in the morning?

7. Do you usually: (check all that apply to you)
    sleep with someone else in your bed
    sleep with someone else in your room
   provide assistance to someone during the night (child, invalid, bed partner,         animal)

8. Is your sleep often disturbed by:
   bed partner
   not being in your usual bed

9. Are your sleep habits on weekends different from the rest of the week?
    yes - please explain       

10. With whom are you now living?(wife, husband, children, parents, etc. and their ages)                  

11. Do you work split shifts or rotating (variable) shifts?  

      If so, what is your schedule?                                        

12. Do you usually drink coffee or tea within 2 hours before you go to bed?

13. Do you do physical exercises before you go to bed?

14. Do you read before falling asleep?

15. Do you take naps during the afternoon or evening?
     frequently - if so, for how long 

16. Do you feel refreshed after a short (10-15 minute) nap?

17. How do you feel after an average night of sleep?
     usually feel drowsy and/or tired if so, for how long:
1 hour2 hours 3 hours
     most of the time,  I feel good
     consistently, I feel good

18. Do you feel better during:
     morning           afternoon          evening

19. Do you take any kind of medication?
Name                           Amount                       How often                   Reason

20. List your daily consumption of the following:





Other Drugs 

Over the counter drugs 






Your Name

Date of Birth

Email ID :

Contact No.

Please complete this self-test to assist us in assessing your sleep.

How tired are you, and how likely are you to doze off at inappropriate times?
Read the following situations and use the scale provided to rate your sleepiness.

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

SituationChance of Dozing
Sitting and Reading0123
Watching TV0123
Sitting inactive in a public place0123
As a passenger in a car for one hour without a break0123
Lying down to rest in the afternoon0123
Sitting and talking to someone0123
Sitting quietly after lunch (without alcohol)0123
In a car, stopped for a few minutes in traffic0123

Total Score: 

Please bring this and completed Life History the night of your sleep study.

Sleep Disorders & Test

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