Setting the Platinum Standard in Sleep Disorders Medicine.™
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Sleep Questionnaire

Please take a few minutes to complete our online sleep survey so we can learn more about the public's sleep habits. All information is confidential and reviewed by Dr. Simmons.
In order to assist us in processing forms fill in all fields. If a field does not apply in your circumstance, please enter "N.A."
Please do NOT press your "Enter" key while filling out this form.

If you are experiencing problems viewing or submitting this form you can download a printable version HERE.(.pdf)


Date:          
First Name: 
Last Name:  
Email:    
Home Phone:    
Work Phone :    
Cell Phone / Mobile:  
Insurance name:    
Insurance policy number:    
Insurance group number:    
Insurance phone number:    
Age: |  Date of Birth: | Gender: M F
Height: ft. - in.  |   Weight:  lbs. 


This questionnaire is used for all of Dr. Simmons programs: please choose the clinic location you wish the response to be directed to (mandatory):

Houston Medical Center
Sugar Land
The Woodlands

1. Have you had a sleep study before? |  Yes or No

If yes, are you currently on CPAP/BiPAP? |   Yes or No   

If you are currently on CPAP or BiPAP then your responses below should be in the context of how you are while using your treatment.  

2. What time do you typically go to bed?
When do you typically wake up to start your day?

3. Do you have difficulty falling asleep? |  Yes or No

If yes, how long does it take to fall asleep or back to sleep?

If yes, do you plan your next day while lying in bed trying to fall asleep?
Yes or No

If yes, do you have racing thoughts going through your mind while trying to fall asleep?
| Yes or No

4. Do you have difficulty staying asleep? | Yes or No

If yes, how many times do you wake up during the night?
If yes, how long does it take you to return to sleep?

5. Do you take medications to fall or stay asleep? | Yes or No    

If yes, please state medication name and dosage:

6. Do you feel refreshed when you awaken to start your day? | Yes or No

7. Do you experience an unsettled, restless sensation in your legs while lying in bed? | Yes or No

If yes, how often? | Rarely (25%)   | Half the time (50%) |  Most of the time (75% or more)
If yes, does movement of your legs calm down the restless sensations at least briefly? | Yes or No

8. Have you been told that you kick or twitch your legs while you are asleep? | Yes or No

9. Do you snore at night? | Yes or No

If yes, how would you rate the severity? | Mild   | Moderate   | Severe

10. Have others told you that you have pauses in breathing or that you make gasping sounds when sleeping? Yes or No

If yes, how frequent are the pauses or gasping?
Throughout the night Frequently Occasionally

11. Does your bed partner frequently sleep in another room because of how you sleep?
Not Applicable Yes or No

12. Check those that apply to you:

Do you frequently wake up with a:
dry mouth headache excessive sweating heart burn
chest pain clenching jaws (or grinding teeth) in sleep
choking or gasping drooling on the pillow
bed wetting (loss of bladder control)
nasal congestion on awakening (which was not present when you went to bed)

13. Do you have unusual behaviors in your sleep? Yes or No

If yes, how often?
When did this start to occur?

If yes, briefly describe what you do in your sleep:

If yes, what part of the night do these typically occur?
Within the first 90 minutes first 3 hrs last 3 hrs of sleep
 

14. Do you have difficulty maintaining concentration during the day?
| Yes or No

15. Are you sleepy during the day? | Yes or No

16. Do you take naps often? | Yes or No  

if so for how long?
Do you usually dream during these naps? | Yes or No

17. What is your daily consumption of:

Caffeinated beverages
Alcoholic beverages
Tobacco products

18. Do you occasionally awaken feeling paralyzed? | Yes or No

19. Do you experience sudden loss of strength in your legs or arms during the day? | Yes or No

If yes, are these brought on by a sudden frightening event or laughter? | Yes or No


Rank how likely it would be for you to become drowsy (like you’re going to fall asleep, rather than just feeling tired) during the day in the following situations:

0= never become drowsy 1= rarely become drowsy 2= frequently become drowsy 3= always become drowsy


Sitting and reading: 0 1 2 3
Watching TV: 0 1 2 3
Sitting inactive in a public place (e.g. theater): 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 the traffic:
0 1 2 3


My sleep problems are:

My other medical problems are:

My medications are:

Have you had a sleep study before? |  Yes or No

If yes, when and where?
  

Have you had surgery for sleep apnea before? |  Yes or No   
Do you need assistance at night by other people? |  Yes or No  
Do you have COPD? |  Yes  or No   
Are you on Oxygen at night? | Yes or No  

Who filled out this Questionnaire?
Referral Source:
(Who referred you or how did you learn about us?)

Is this the first contact / communication you are having with our office ? | Yes or No
If No, then please state approximately when and where prior contact took place: (also note if you were directed to this page from our office while providing your personal information.)


YOU MUST ENTER THE SECURITY WORDS IN THE BOX BELOW BEFORE SUBMITTING THE FORM.



 


Find a Sleep Center in Houston:

locations, maps and contact information

More Information >>

 


About Dr. Simmons:

More information on Dr. Jerald H. Simmons and his Practice.

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