[PDF] Sleep Quiz
breathing while I sleep □ I am tired during waking hours almost daily staying alert and fight sleepiness often □ I have fallen asleep while driving or in social sleeping □ I am told I experience unusual behavior while sleeping (i e , nightmares, night terrors, sleep Sleep apnea causes you to stop breathing while
[PDF] SLEEP QUESTIONNAIRE - ProSites
□Heart Disease □Diabetes □Stroke □Seizures/ Epilepsy □Sleep Apnea As a passenger in a car for an hour without a break In the evening, I usually start feeling tired at: The total amount of time I am awake during the night after I first fall asleep is: ______ I have been told that I stop breathing when I sleep
[PDF] Confidential Sleep Questionnaire - Paloma Medical Group
Do you have trouble sleeping when you are doing shift work? □ Yes □ No ______ a m /p m ______ a m /p m same as bedtime □ tired Do you nap or doze during the day? □ Yes □ No How long is your nap in the AM? _____ mins/ hours Are How often have you been told that you stop breathing during sleep? □
[PDF] Sleep Questionnaire Template EMR
weekday weekend Typical hours in bed: hours Typical hours of sleep: hours Yes □ No — I smoke prior to bedtime or when I awaken during the night Yes □ No — I have been told that I stop breathing while asleep How likely are you to doze of of fall asleep in the following situations, in contrast to feeling just tired
[PDF] Sleep Questionnaire
CHECK ALL THAT APPLY: □ I feel sleepy during the daytime □ I have been told I snore □ I have been told I stop breathing in my sleep □ I wake up gasping
[PDF] SLEEP ASSESSMENT - Western Reserve Hospital
8 Do you have a history of teeth grinding? □ YES □ NO 9 Do you wear an oral Have you been told that you stop breathing during sleep? □ Yes On weekdays I go to bed at _____ am/pm and wake up at _____ am/pm How likely are you to doze off or fall asleep in the following situations, in contrast to feeling tired?
[PDF] Sleep History Questionnaire - Sandhills Neurologists
□Gasping / choking / repeated pauses in breathing while sleeping □ Difficulty □Unusual behavior(s) during sleep (walking, talking, etc ) □am □pm □am
[PDF] Patient Questionnaire - Polk Starlight Sleep Labs
I have been told that I stop breathing or gasp for breath while I sleep, although I do not remember this when I wake up □ 3 I have high blood pressure □ 4 My
[PDF] I CINÉMATIQUE ET CHANGEMENT DE RÉFÉRENTIELS. 1. Préparation ... rappel : référentiel = solide (indéformable) + horloge = observateur. I.1 Prérequis<
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