Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

SUNIL LALLA, MD FCCP

Sleep questionnaire

First Name * Last Name * Date of Birth * Date of Completion * Do you snore? * Do you stop breathing at night? * Do you wake gasping/choking? * Do you have restless sleep? * Do you disrupt your partners sleep? * Do you wake with headaches? * During the daytime do you experience fatigue, tiredness or lethargy? * Do you fall asleep while driving or talking? * Do you fall asleep while watching TV or at Church? * Do you wake with heartburn or sour taste? * Do you wake with chest pain? * Do you walk/talk in your sleep? * Do you have leg/arm jerks during sleep? * Do you grind your teeth during sleep? * Do you wet the bed at night? * Do you have unusual movements or sounds during sleep? * Do you have nightmares or bad dreams? * Do you feel unable to move your body upon falling asleep or upon wakening? * Do you experience vivid dreams during a daytime nap? * Do you feel a sudden muscle weakness when laughing or angry (emotional)? * Do you experience vivid dream-like scenes or hallucinations while awake? *

Epworth sleepiness scale

The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations. Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3, with 0 meaning you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation. How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think about how they would have affected you.

Sitting and reading * Watching TV * Sitting inactive in a public place * Being a passenger in a motor vehicle for an hour or more * Lying down in the afternoon * Sitting quietly after lunch (no alcohol) * Stopped for a few minutes in traffic while driving * TOTAL * Signature: * Date of Completion: *