Center for Sleep & Wake Disorders
Follow-up Questionnaire
Please fill out this form and then click "Submit" when finished
(*=required field)
First name:*    Last name:*           
Date of Birth:*  
Current Primary Care/Internist:*   Date of last physical:*  
Current weight (in pounds):   (Please only enter numbers; if unknown, please leave blank)
Height (feet):*     Height (inches):*   
What is the main sleep problem that you are seeing us for?*   
New medical problems or changes in old ones:   

Please answer these questions about your sleep and wakefulness since your last visit:
How has your sleep problem been since your last visit?*           
Please use this space for any additional info about your condition since your last visit:

What time are you getting in bed, on average?*   
About what time do you turn off the lights and try to go to sleep?*   
Approximately how long does it take you to fall asleep?* 
About how many hours of sleep do you get on an average night?*   
How many awakenings are you experiencing on an average night?*  

What are the times of typical awakenings?
8pm-10pm    10pm-12mid    12mid-2am    2am-4am    4am-6am    6am-8am
 8am-10am    10am-12n    12n-2pm    2pm-4pm    4pm-6pm    6pm-8pm

What is the average duration of these awakenings?
 <5 min    5-15 min    15-30 min    30-60 min    60-90 min    90 min - 2 hours    >2 hours

Why do you think you awaken?  
Need to use bathroom bedpartner awakens you own snoring awakens you pets   no clear reason  other
If other, please elaborate:

What time do you get up on most workdays?*
What time do you get up on most weekends?*
How much variability is there from night to night?
How do you feel when you awaken in the morning?*   
Please rate your daytime sleepiness (0 is none, 5 is severe)*  

Over the past week how likely would you be to fall asleep in the following situations? (0 is not likely, 3 is very likely)
Sitting and reading* 0 1 2 3
Watching TV* 0 1 2 3

Sitting in a public place*

 0 1 2 3

As a passenger in a car for an hour*

 0 1 2 3

Lying down to rest in the afternoon*

 0 1 2 3

Sitting and talking to someone*

 0 1 2 3

Sitting quietly after lunch with no alcohol*

 0 1 2 3

In a car, stopped for a few minutes in traffic*

 0 1 2 3

Epworth Sleepiness Scale (Johns MW. Sleep 1991;14:540-545)

How many naps do you take per week?*  
Average nap length:*  
Caffeinated beverages/day:*    
Alcoholic beverages/week:*  
About how many hours of exercise do you get each week?:    

Are you a current cigarette smoker?*     
        If yes, how many packs per day?      How often do you smoke within two hours of bedtime? 

Recreational drug use?:*     If yes, please elaborate:  

Do you use CPAP? (If no, skip to medications section)  
Is CPAP helping?   
Are you still snoring? 
How many nights per week do you use your CPAP?   
How many hours/night?
Please describe any problems you are having with your CPAP:
Please list your currrent medications, including any over-the-counter (OTC), vitamins, and supplements.
Please include dosages, times of day (e.g. morning, bedtime), and the prescribing physician if you have this information):
If none, please check here:   // If you have been seen by us in the previous 12 months, and there have been no changes to your medications, please check here:
Name of medication Dose Time(s) (e.g. morning / bedtime) Prescribing Doctor
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
If any additional meds, please enter here: