Patient Sleep Form - Altru Health System

* 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

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Patient Information

Sleep History