Pulmonary and Medicine Associates

Pulmonary and Medicine Associates, PLLC

27472 Schoenherr, Suite 100

Warren MI 48088

Phone: 586-751-8844

SLEEP MEDICINE QUESTIONNAIRE

In order to better understand your sleep problem, please accurately answer the following questions.

Name *

Date of Birth *

Occupation

Name of Doctor referring you

Why are you being referred to our sleep center? *

At what age did your sleep problem begin? *

How does it affect your life and daily activities?

Have you had any previous evaluations, examinations, or treatment for this problem? *

Yes

If yes, please describe

If employed, what are your working hours?

Start

Stop

How many days a week do you work?

Do you have a regular bed partner? *

Yes

What do you do just before bed (e.g., reading, T.V., bath, etc.)? *

The following is a list of symptoms that may be experienced by people with sleep problems. Please mark those symptoms that you have experienced.

Number of days/ weeks that you have these symptoms:

Have you been in a car accident due to falling asleep at the wheel? *

Yes

Near Miss

Question:

Workdays

Days Off
Question:

Regular Coffee

Workdays:

# cups (8 oz) per day

Days Off:

# cups (8 oz) per day
Question:

Tea

Workdays:

# cups (8 oz) per day

Days Off:

# cups (8 oz) per day
Question:

Caffeinated soft drinks

Workdays:

glass (12 oz) per day

Days Off:

glass (12 oz) per day
Question:

Beer

Workdays:

can or bottle (12 oz) per day

Days Off:

can or bottle (12 oz) per day
Question:

Wine Cooler

Workdays:

can or bottle (12 oz) per day

Days Off:

can or bottle (12 oz) per day
Question:

Wine

Workdays:

glass (12 oz) per day

Days Off:

glass (12 oz) per day
Question:

Liquor

Workdays:

shots per day

Days Off:

shots per day

Have you had your tonsils taken out? *

Yes

Please list any other surgeries you've had:

Have you been hospitalized for other reasons? *

Yes

Why?

Family history

Sleep problems *

Yes

Heart Disease? *

Yes

Stroke? *

Yes

Cancer? *

Yes

Please read this list of body systems and symptoms. If you recently had any of these problems, please check them. You may use the input 'Describe other problems/symptoms' to describe the problem or add other symptoms you may have.

CONSTUTIONAL

Symptoms

Fever

Change in weight

Describe other problems/symptoms

EYES

Symptoms

Change in vision

Describe other problem/symptoms

EAR, NOSE, THROAT

Symptoms

Trouble Hearing

Sinus Trouble

Trouble Speaking

Trouble Swallowing

Describe other problem/symptoms

CARDIOVASCULAR

Symptoms

Chest Pain

Irregular Heartbeat

Heart Attack

High Blood Pressure

Stroke

Phlebitis

Cholesterol Problems

Describe other problem/symptoms

RESPIRATORY

Symptoms

Shortness of breath

Wheezing

Cough bronchitis

Emphysema

Asthma

Describe other problem/symptoms

GASTROINTESTINAL

Symptoms

Abdominal pain

Diarrhea

Constipation

Ulcers

Rectal bleeding

Describe other problem/symptoms

MUSCULOSKELETAL

Symptoms

Aches and pains in joints or muscles such as backache

Swelling in legs

Describe other problem/symptoms

BREAST AND SKIN

Symptoms

Birthmarks

Change in moles

Lumps in breasts

Describe other problem/symptoms

NEUROLOGIC

Symptoms

Balance problems

Weakness in face, arms, or legs

Describe other problem/symptoms

ENDOCRINE

Symptoms

Heat or cold intolerance

Excessive thirst

Thyroid

Change in shoe size

Describe other problem/symptoms

HEMATOLOLOIC

Symptoms

Easy bruising

Bleeding

Swollen Glands

Describe other problem/symptoms

ALLERGIC/ IMMUNOLOGIC

Symptoms

Allergies to food

Allergies to Medicine

Allergies to other substances

Hay fever

Mold

Describe other problem/symptoms

PSYCHIATRIC

Symptoms

Change in Mood

Depression

Problems with controlling anxiety

Describe other problem/symptoms

Signature of Patient *

Press save, to finish your signature