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Notification
LET'S EVALUATE YOUR SlEEP
Sleep Questionnaire for Patients
Have you been told that you snore excessively, or that your breathing is interrupted while you sleep?
Do you feel sleepy or fatigued during the day?
Do you doze off while reading, watching television or driving?
Do your legs jerk frequently or feel uncomfortable (restless) before or during sleep?
Do you have trouble falling asleep?
Do you awake with a headache?
Do you experience memory loss?
Do you awake gasping for air?
Do you find your heart beating irregularly at night?
Do you awake in the morning without feeling refreshed?
Do you ever experience sleep paralysis?
Do you want us to contact you regarding your sleep?
First Name:
Last Name:
Date of Birth:
(MM/DD/YYYY)
Male
Female
Height:
ft
inches Weight
lb
What type of insurance do you have?
Company plan
Individual plan
None
Insurance company name:
PPO
HMO
Medicare
Email:
Area code:
Phone:
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How did you hear about Bay Sleep Clinic?
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