Sleep Questionnaire :: North Vancouver Sleep Disorders Clinic and Laboratory

North Vancouver Sleep Clinic Intake Form

Demographics

Last Name:

Year of Birth:

Height (Feet/Inches):

Weight (LBs):

BMI (kg/m²):

Occupation:

Past Sleep Evaluation and Treatment

Past Medical History

Sleep Pattern

Typical bedtime on Weekdays (am/pm)
Typical bedtime on Weekends (am/pm)
Typical amount of time it takes to fall asleep
Typical number of awakenings per night
List any activities that you normally do during nighttime awakening(s) (i.e. bathroom, eat, watch TV)
Typical amount of time to fall back asleep after an awakening
Typical wake up time on Weekdays (am/pm)
Typical wake up time on Weekends (am/pm)
Morning Headaches	Yes	No
Morning Fatigue	Yes	No
How do you usually awaken (i.e. alarm clock?)
Typical time you get out of bed on Weekdays (am/pm)
Typical time you get out of bed on Weekends (am/pm)
Total amount of sleep per night
Number of naps per day

Breathing

Sleep Habits

Please check all of the following statements that are true about your sleep

Daytime Sleepiness

Other Symptoms

Employment Status

Substance Use

FAMILY HISTORY OF SLEEP DISORDERS

Epworth Sleepiness Scale

How likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times.

Even if you haven’t done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.

Use the following scale to choose the most appropriate number for each situation.

0 = Would never nod off
1 = Slight chance of nodding off
2 = Moderate chance of nodding off
3 = High chance of nodding off

BOSS (Bordeaux Sleepiness Scale)

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

	I usually watch TV in bed prior to sleep
	I am on my phone at night in bed
	I drink alcohol prior to bedtime
	I smoke prior to bedtime or when I awaken during the night
	I eat a snack at bedtime
	I eat if I wake up during the night
	I typically wake up from sleep to go to the bathroom
	I have trouble falling asleep
	I often wake up during the night
	I am unable to return to sleep easily if I wake up during the night
	I have thoughts that start racing through my mind when I try to fall asleep
	I wake up early in the morning, and I am still tired but unable to return to sleep
	I have nightmares as an adult
	I sweat a great deal during sleep
	I cannot sleep on my back
	I often travel across 2 or more time zones
I sleep Alone With a Bed Partner With Pets With Children

Do you Smoke?	Yes	No
If Yes, how much?
Do you use marijuana?	Yes	No
Do you use any recreational drugs?	Yes	No
Do you drink alcohol?	Yes	No
Do you drink alcohol to go to sleep?	Yes	No
How many alcoholic drinks do you drink? (for example 1/d or 1/week etc)
How much coffee do you drink? (for example 1/d or 1/week etc)
How much tea do you drink? (for example 1/d or 1/week etc)
How much cola do you drink? (for example 1/d or 1/week etc)
How much chocolate do you take? (for example 1/d or 1/week etc)

Sleep Apnea?	Yes No Unknown
Snoring?	Yes No Unknown
Restless Legs?	Yes No Unknown
Narcolepsy?	Yes No Unknown
Excessive Daytime Sleepiness?	Yes No Unknown
Insomnia?	Yes No Unknown
Other Sleep Disorder?	Yes No Unknown

Sitting and reading	0	1	2	3
Watching TV	0	1	2	3
Sitting, inactive, in a public place (e.g., in a meeting, theater, or dinner event)	0	1	2	3
As a passenger in a car for an hour without a break	0	1	2	3
Lying down to rest in the afternoon when circumstances permit	0	1	2	3
Sitting and talking to someone	0	1	2	3
Sitting quietly after a meal without alcohol	0	1	2	3
In a car, while stopped for a few minutes in traffic or at a light	0	1	2	3
Epworth Total Score (calculated from above questions):

Gender			Female	Male
Number of km driven per year			Less than 20,000km/year	Equal to or more than 20,000km/year
Recently, how likely are you to doze off or fall asleep in contrast to feeling just tired in a car while stopped for a few minutes in traffic?	Would never doze	Slight chance of dozing	Moderate chance of dozing	High chance of dozing
Have you experienced in the previous year at least one episode of severe sleepiness at the wheel that made driving difficult or forced you to stop the car?	No, never	Yes, but less than once a month	Yes, at least once a month	Yes, at least once a week
BOSS Total Score (calculated from above questions):

Hypertension (High Blood Pressure)	Yes	No
Heart Disease	Yes	No
Diabetes	Yes	No
Atrial Fibrillation	Yes	No
Congestive Heart Failure	Yes	No
Depression	Yes	No
Anxiety	Yes	No
Lung Problems/COPD/Asthma	Yes	No
Chemical Dependency or Abuse	Yes	No
Back or Joint Problems (Arthritis)	Yes	No
Acid Reflux	Yes	No
Chronic Sinus Problems	Yes	No
Fibromyalgia	Yes	No
Chronic Pain	Yes	No
Stroke or TIA	Yes	No
Seizures	Yes	No
Drug Addiction	Yes	No
Use Of Opiate Pain Killers	Yes	No
Female: Menopausal Hot Flashes	Yes	No
Male: Prostate Problems	Yes	No
Male: Erectile Dysfunction	Yes	No

I wake up with pain	Yes	No
I have had sudden muscle weakness (during the day) in response to emotions such as laughter, anger, or surprise	Yes	No
I have had an inability to move while falling asleep or when waking up (sleep paralysis)	Yes	No
I have had hallucinations or dreamlike images or sounds when falling asleep or waking up	Yes	No
I act out my dreams	Yes	No
I have aggressive behaviour during sleep (punching, injuring others)	Yes	No
I have fallen out of bed	Yes	No
I have had episodes of sleep talking	Yes	No
I grind my teeth	Yes	No
I have restless legs (Uncomfortable sensations in your legs that make you want to move them.)	Yes	No

Employment Status	Employed Unemployed Disability Retired
My job requires driving a vehicle	Yes	No
I work with dangerous equipment or substances	Yes	No
I am a shift worker	Yes	No

Little interest or pleasure in doing things	0	1	2	3
Feeling down, depressed, or hopeless	0	1	2	3
Trouble falling or staying asleep, or sleeping too much	0	1	2	3
Feeling tired or having little energy	0	1	2	3
Poor appetite or overeating	0	1	2	3
Feeling bad about yourself – or that you are a failure or have let yourself or your family down	0	1	2	3
Trouble concentrating on things, such as reading the newspaper or watching television	0	1	2	3
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
Thoughts that you would be better off dead or of hurting yourself in some way	0	1	2	3
PHQ-9 Total Score (calculated from above questions):