Patient Sleep Form - Altru Health System - Grand Forks, ND

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Home > Services > Sleep Center > Patient Sleep Disorder Questionnaire

* Denotes required fields

* Today's Date mm/dd/yyyy

Patient Information

* First Name

M.I.

* Last Name

* Address

* City

* State Example: NY

* ZIP Code Example: 12345

* Home Phone Example: 123-123-1234 x123

Work Phone Example: 123-123-1234 x123

* Email

* Date of Birth mm/dd/yyyy

* Age

* Marital Status

* Height Example: 5'6"

* Weight

* Neck Size

Attending Physician

Physician referring you to the Sleep Lab

Occupation

Employer

Sleep History

* What time do you typically go to bed? Example: 12:00 AM

* Do you have difficulty falling asleep at the beginning of the night?

Yes
No

* Do you have racing thoughts going through your mind while trying to fall asleep or after waking up in the middle of the night?

Yes
No

* Do you have difficulty staying asleep throughout the night?

Yes
No

* Do you take medications to fall or stay asleep?

Yes
No

* Do you awaken at night to use the bathroom?

Yes
No

* When do you typically wake up to start your day?

* Do you need an alarm clock?

Yes
No

* Do you feel refreshed when you awaken to start your day?

Yes
No

* Do you experience an unsettled, restless sensation in your legs while laying in bed?

Yes
No

* Have you been told that you make kicking and twitching movements while asleep?

Yes
No

* Do you snore at night?

Yes
No

* Have others told you that you have pauses in breathing or that you make frequent gasping sound when sleeping?

Yes
No

* Does your bed partner frequently sleep in another room because of how you sleep?

Yes
No

Sleep Center

Patient Instructions for Sleep Study
Patient Sleep Disorder Questionnaire
Sleep History Questionnaire for Physicians
Sleep Study FAQ
Sleepiness Scale

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