Comprehensive Sleep and Breathing Disorders Center, P.C.
1406 McFarland Boulevard NE, Suite C Tuscaloosa, AL 35406 www.csleepcenter.com
Email:compsleepctr@comcast.net
P 205.343.0004 | F 205.343.0092
SLEEP HISTORY
Primary MD:
NAME:
Other MD’s seen:
SEX: M F
Consulting MD:
AGE:
Date:
(For the following, Circle as applicable, may take the help of companion or nurse)
CHIEF COMPLAINT: Daytime sleepiness, Insomnia, Snoring, Breathing difficulty, Leg jerks, Fatigue
How long has it bothered you? Less than 3 months, 6-12 months, 1-2 years, longer than 2 years
OTHER:
Snoring- Do you snore? Yes No If yes, Severity – Mild Moderate Loud
Very loud
How long?
Worse on- side back
Does it awaken you? Yes No
Apnea-Do you or have you been told that you stop breathing during sleep? Yes No .
If yes, How frequently?
Do you snore, then pause? Yes No
How long are pauses in sleep?
How long ago did they start?
Does patient look like s/he is trying to breathe but can't get breath in?
Does patient then take a long breath or snort and partly awaken?
Awakening: Do you awaken in sleep? Yes No if yes, Describe
Do you have trouble trying to sleep? Yes No if yes, Describe:
Shortness of breath or choking upon awakening? Yes No
Any burping up of sour fluid from stomach? Yes No
AROUND-THE-CLOCK HISTORY:
Usual Bedtime:
How long after bedtime before sleep onset?
What do you do before bedtime? TV READ WORK COMPUTER OTHER:
Is bedtime regular? Yes No
Shift Work? Yes No
Weekend changes from regular bedtime
Number of awakenings and reasons for awakenings:
Usual duration of awakenings:
Clock-watching when awake Yes No
TV and other in-bed habits Yes No
Wake-up time:
How do you feel when you awaken? Sleepy Groggy Unrefreshed Other:
Physical discomfort that disturbs sleep Yes No
Insomnia: Unable to sleep or wake up early: Yes No How long? Years Months Days
Difficulty with: Sleep Onset Maintenance or Both
Is it better in: Another room? Yes No Another Place? Yes No On vacation Yes No On weekend? Yes No
ANY OTHER DETAILS:
Parasomnia:
Do you have leg twitching jerking or achy/ crawly sensation before bed time? Yes No
Is it worse at night and improves on movement or walking Yes No
Do you act out your dreams? Yes No
Sleep walking Yes No
Nocturnal Eating Yes No
Teeth Grinding Yes No
Nightmares Yes No Bedwetting Yes NoLeg cramps during sleep Yes No
ANCILLARY SYMPTOMS:
Memory loss Yes No
Decreased concentration Yes No
Weight gain Yes No
Automatic behavior (walk into room and forget mission) Yes No
Sexual dysfunction Yes No
Erectile dysfunction (if applicable) Yes No
Increased urination Yes No Wake up to urinate Yes No
How many times?
Morning headaches Yes No
Irritability Yes No
Fatigue Yes No
Excessive sweating Yes No
Dry mouth in the morning Yes No
EXCESSIVE SLEEPINESS IN DAYTIME:
Do you feel sleepy during the day? Yes No If yes, When did it start? Days Months Years
Do you feel sleepy during:
TV
Work
Reading
Driving
Getting worse? Yes No
How severe is daytime sleepiness? Mild Moderate Severe
Feel knees buckle, arms weak, or jaws droop when mad happy or sad? Yes No
Experience or act out vivid dreams? Yes No
Unable to move upon awakening or falling asleep Yes No
Daytime naps: Yes No
If yes, Frequency:
Refreshing? Yes No
Childhood
Epiworth Sleepiness Scale:
Use the following scale to choose the most appropriate number for each situation during awake hours-indication of feeling sleepy
and not falling asleep
0 = would never doze
1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
SITUATIONS:
1) Sitting and reading
0 1 2
3
2) Watching T.V.
0 1 2
3
3) As a passenger in a car for 1 hour without a break
0 1 2
3
4) Sitting inactive in a public place (theater, park)
0 1 2
3
5) Lying down to rest in the afternoon
0 1 2
3
6) Sitting and talking to someone
0 1 2
3
7) Sitting quietly after lunch(No alcohol)
0 1 2
3
8) In a car stopped in traffic
0 1 2
3
TOTAL:
****************************************STOP HERE**************************************************
PHYSICAL EXAMINATION: Constitution:
HEENT
NOSE:
Nostrils:
Septal deviation:
Polyps:
Apparent Obstruction:
R
L
MOUTH:
Tonsils
Dentition
Tongue
Uvula
Pharynx
Jaw
NECK:
JVD
Lymph nodes
Strides
Shape
Thyroid
Neck vein
Carotids
CHEST:
OBS
Palpitations
Percussion
Auscultation
SKIN:
LYMPH:
Neck
Supraclavicular
HEART:
ABDOMEN:
Config.
Liver
Spleen
EXTREMITIES:
Edema
Cyanosis
MENTAL STATUS
Mood
Affect
Sleepiness
NEUROLOGIC:
CNS
DTR
TESTS: CXR PFT
EKG TSH
LXSCOPE
OTHER
IMPRESSION/PLAN:
PSG: BASELINE
MSLT
2 NIGHT
SEIZURE MONTAGE
SPLIT NIGHT
VIDEO-PSG
CPAP
RBD PROTOCOL