Kaiser San Jose Sleep Questionnaire

Kaiser San Jose Sleep Questionnaire

Date:_____________________________________ Name:____________________________________ MR#___________________ Sex:______ Age: ______ Height:______ Weight:______ Phone Number: (H)________________(W)_______________ Please describe your sleep problem and length of time you have had it:_______________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. Do you work rotating shifts? ____Yes ____No What time do you usually go to bed? _____________(Indicate “variable” if bed time varies widely, such as with rotating shift work.) What time do you usually get up? ________________(Indicate “variable” if arising time varies widely, such as with rotating shift work.) How long does it usually take you to fall asleep? ____________________________. How many times in the night do you usually go to the bathroom? _______________. How many hours do you usually sleep each night?_______. Do you snore? ____Yes ____No If yes, do you snore loudly enough to bother other people? _____Rarely ______Sometimes ____Always or almost always Do you stop breathing while asleep? ____Yes ____No Have you been diagnosed with sleep apnea? ____Yes ____No If yes, what treatment(s) have you had? _____CPAP _____Dental Appliance _____Surgery _____Position Therapy In bed: Do your legs feel restless? ____Yes ____No Do you often get heartburn? ____Yes ____No Do you usually breathe through your mouth? ____Yes ____No In the morning: Do you often have a headache? ____Yes ____No Do you usually have a dry mouth? ____Yes ____No Do you usually feel rested? ____Yes ____No

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Kaiser San Jose Sleep Questionnaire (Continued)

Please list your current medications (include prescription, over-the-counter drugs and alternative therapies): ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. Do you smoke cigarettes? ____Yes ____No (If yes, how many per day?________) How many alcoholic beverages do you usually have per day? _________. How many beverages with caffeine do you usually have per day? ______. Do you have a history of (check all that apply): _____High blood pressure _____Heart attack _____Stroke _____Other medical and psychiatric problem(s)___________________________ ___________________________________________________________. ************************************************************************ How likely are you to doze 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 have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0=No chance of dozing 1=Slight chance of dozing 2=Moderate chance of dozing 3=High chance of dozing Situation Chance of Dozing (Circle your answer) Sitting and reading 0 1 2 3 Watching TV 0 1 2 3 Sitting inactive in a public place 0 1 2 3 (i.e., a theater or a meeting) As a passenger in a car for an hour 0 1 2 3 without a break Lying down to rest in the afternoon 0 1 2 3 when circumstances permit Sitting and talking to someone 0 1 2 3 Sitting quietly after a lunch without 0 1 2 3 alcohol In a car, while stopped for a few 0 1 2 3 minutes in traffic

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