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SLEEP QUESTIONNAIRE

Please take a few minutes to complete our online sleep survey so we can learn more about the public's sleep habits. All information is confidential and reviewed by Dr. Simmons.

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In order to assist us in processing forms fill in all fields. If a field does not apply in your circumstance, please enter "N.A." Please do NOT press your "Enter" key while filling out this form.

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If you are experiencing problems viewing or submitting this form a printable version in PDF format is available here.

Gender

If you are currently on CPAP or BiPAP then your responses below should be in the context of how you are while using your treatment.

1.) Have you had a sleep study before?
3.) Do you have difficulty falling asleep?
If yes, do you plan yornext da while yinginbed tring to fall asleep?
If yes, do yo have racing thouhts going through your mind whle trying to fall asleep?
4.) Do you have difficulty staying asleep?
5.) Do yo take medicaton to fall or stay asleep?
6.) Do yo feel refreshed when you awaken to start your day?
7.) Do you experience an unsettled, restless sensation in your legs while lyingin bed?
If yes, does movement of your legs calm down the restless sensations at least briefly?
8.) Have you been told that you kick or twitch your legs while you are asleep?
9.) Do you snore at night?
10.) Have others told you that you have pauses in breathing or that you make gasping sounds when sleeping?
11.) Does your bed partner frequently sleep in another room because of how you sleep?
12.) Do you freuquently wake up with a (check those that apply to you):
13.) Do you have unusual behaviors in your sleep?
14.) Do you have difficulty maintaining concentration during the day?
15.) Are you sleepy during the day?
16.) Do you take naps often?
Do you usually dream during these naps?
18.) Do you occassionally awaken feeling paralyzed?
19.) Do you experience sudden loss of strength in your legs or arms during the day?
If yes, are these brought on by a sudden frightening event or laughter?

Rank how likely it would be for you to become drowsy (like you're going to fall asleep, rather than just feeling tired) during the day in the following situations:

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     0 = Never become drowsy

     1 = Rarely become drowsy

     2 = Frequently become drowsy

     3 = Always become drowsy

Sitting and reading:
Watching TV:
Sitting inactive in a public place (e.g. theater):
As a passenger in a car for an hour without a break:
Lying down to rest in the afternoon when circumstances permit:
Sitting and talking to someone:
Sitting quietly after lunch without alcohol:
In a car while stopped for a few minutes in the traffic:
Have you had a sleep study before?
Have you had surgery for sleep apnea before?
Do you need assistance at nightly by other people?
Do you have COPD?
Are you on oxygen at night?
Is this your first contact with our office?

Thanks for submitting your information. A member of our staff will be in contact with you soon.

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