Medical Questionnaire – Sleep Assessment Last Name(Required) First Name(Required) Date of Birth(Required) DD dash MM dash YYYY In the following situations, what is the risk that you will tend to fall asleep? Check the answer that represents your reality.While you're busy reading a document No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep In front of the television or at the cinema No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Sitting inactive in a public place (waiting room, theatre, classes, congresses, etc.) No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Passenger, for at least one hour without interruption, of a car or public transport (train, bus, plane, metro, etc.) No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Lying down in the afternoon when circumstances allow No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Sitting quietly at the table at the end of a non-alcoholic meal No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Behind the wheel of a car that has been immobilized for a few minutes in a traffic jam No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Sitting during a conversation (or on the phone) with a loved one No chance of dozing off or falling asleep Low chance of falling asleep Medium chance of falling asleep High chance of falling asleep Sleep Apnea ScreeningAnswer what applies to you most of the time.Do you snore loudly (loud enough to be heard through closed doors, or for your bed partner to nudge you at night because of your snoring)? No Yes Do you often feel tired, exhausted, or sleepy during the day (for example, do you fall asleep at the wheel)? No Yes Has anyone noticed that you stop breathing or desperately choke/search for air while you sleep? No Yes My approximate sweater collar size is: More than 17 inches (Men) or 16 inches (Women) Less than 17 inches (Men) or 16 inches (Women) Do you have high blood pressure or are you receiving treatment for high blood pressure? No Yes Body mass index greater than 35 kg/m2? No Yes Are you over 50 years old? No Yes Gender = Male? No Yes Sleep Hygiene Assessment – Answer what applies to you most of the time My eyes are exposed to fiery white light sources after 8pm (at work, at home, in public places, etc.) I practice sports or physical activities after 8 p.m. I wake up tired and need more sleep. I take naps every day. I take naps for more than 30 minutes. I take naps after 4pm. I can’t fall asleep within 20 minutes when I go to bed. I use my computer, tablet or smartphone within 90 minutes of bedtime. I watch TV or look at my phone/tablet when I’m in bed. I don’t use the CPAP machine that was prescribed to me for a sleep apnea diagnosis in the past. I wake up at night, even if it’s just to go to the bathroom. I can’t fall asleep after waking up in the middle of the night. I sleep in a room with light and/or noise. I feel the need to move my feet or legs the night I’ve been diagnosed with restless leg syndrome in the past. I drink caffeinated beverages, sugary drinks, or alcohol during the day or night that could disturb my sleep. I sometimes experience interpersonal conflicts in the evenings. I have disturbing dreams during the night. I wake up in the morning at irregular hours. I go to bed at irregular hours in the evening. My bedtime schedule is different on weekdays compared to weekends and/or I often sleep on weekends. I take sleeping pills so I can sleep and the sleep problems come back as soon as I stop the medication. I feel so exhausted at night that it prevents me from falling asleep. I have someone in my house who is disturbing my sleep (e.g. young children, snoring partner, partner waking up or going to bed at different times, etc.) My bed is uncomfortable. I can get too hot or too cold at night, which impacts the quality of my sleep. I am exposed to dirt, excess moisture, mold or any unusual odor in my room. I don’t feel safe in my room at night. CAPTCHA
