D42-8101-2+Rev+5+Sleep+Profiler+Meds+Questionnaire
Name:
Date of Birth;
Weight:
Hight:
Neck size :
ID number (optional) :
High Blood Pressure
Yes
No
Restless Leg Syndrome
Yes
No
Narcolepsy
Yes
No
Recent Head Trauma
Yes
No
Painful Condition
Yes
No
Heart Disease
Yes
No
Sleep Apnea
Yes
No
Depression
Yes
No
Stroke
Yes
No
A.M. Headaches
Yes
No
Diabetes
Yes
No
Insomnia
Yes
No
Anxiety or PTSD
Yes
No
Neurological Disorder
Yes
No
Night Sweats
Yes
No
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 haven’t 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 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
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 haven’t 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 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sittinginactive in a public place (theater, meeting, etc)
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 lunch without alcohol
0
1
2
3
In a car, while stopped for a few minutes in traffic
0
1
2
3
Please rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s)
Please rate the CURRENT (i.e., LAST TWO WEEKS) SEVERITY of your insomnia problem(s)
Difficulty falling asleep
Difficulty staying asleep
Problem waking up too early
How SATISFIED or DISSATISFIED are you with your CURRENT sleep pattern?
How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
How WORRIED / DISTRESSED are you about your current sleep problem?
To what extent do you consider your sleep problem to INTERFERE with your CURRENTfunctioning (e.g. daytime fatigue, ability to function at work/ daily chores, concentration,memory, mood, etc.)?
How often during the week do you drink alcoholic beverages in the evening before falling asleep?
Do you drink more than one beverage with caffeine in the afternoon or evening (i.e., coffee,tea, energy or soft drinks)?
For these questions:
Rarely= 0-1times/week
Sometimes=1-2 times/wk
Frequently= 3-4 time /wk
Almost Always= 5+ times/wk
For these questions:
Rarely= 0-1times/week
Sometimes=1-2 times/wk
Frequently= 3-4 time /wk
Almost Always= 5+ times/wk
Do you have problems keeping your legs still at night or need to move them to feel comfortable?
Never
Rarely
Sometimes
Frequently
Almost Always
Do you have vivid or troubling nightmares?
Never
Rarely
Sometimes
Frequently
Almost Always
On average,in the past month, how often have you snored or been told that you snored?
Never
Rarely
Sometimes
Frequently
Almost Always
Do you wake up choking or gasping?
Never
Rarely
Sometimes
Frequently
Almost Always
Have you been told that you stop breathing in your sleep or wake up choking or gasping?
Never
Rarely
Sometimes
Frequently
Almost Always
How often do you take a prescription medication to help you fall asleepor stay asleep?
Never
Rarely
Sometimes
Frequently
Almost Always
How often do you take an ‘Over the Counter’ medication to help you fall asleep or stay asleep?
Never
Rarely
Sometimes
Frequently
Almost Always
Patient Health Questionnaire (PHQ-9): Over the last 2 weeks, how often have you been bothered by any ofthe following problems?
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
Patient Health Questionnaire (PHQ-9): Over the last 2 weeks, how often have you been bothered by any ofthe following problems?
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
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
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
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
Not being able to stop or control worrying
0
1
2
3
Feeling afraid as if something awful might happen
0
1
2
3
Worrying too much about different things
0
1
2
3
Being too restless so that it is hard to sit still
0
1
2
3
Becoming easily annoyed or irritable
0
1
2
3
Feeling nervous, anxious, or on edge
0
1
2
3
Trouble relaxing
0
1
2
3
Do you routinely take any of the following medications?
Do you routinely take any of the following medications?
Ambien (Zolpidem)
Lunesta (Eszopiclone)
Halcion
Rozerem
Sonata (Zaleplon)
Restoril
Intermezzo
Silenor (Doxepin)
Narcotic for Pain
High Blood Pressure
Antidepressant
Anti-anxiety/tranquilizer
Xanax
Steroid
Parkinson’s
Stimulant/ADHD
Email:
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