Dr. Chaudhry Sleep Questionnaire

Please complete this questionnaire as this information will be very helpful for assessment of your sleep disorder.

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Patient Demographics

First Name *

Last Name *

Date of Birth *

Sex *

Height

Weight

BMI

Neck Circumference

Full Address *

Work History (Place of work, job description, shifts worked - including time of shifts)

What is the main problem that you would like the sleep lab to address? *

Previous Clinical Testing & Diagnostics

Have you undergone previous sleep study testing at any sleep facility? YES NO

If YES, where?

When?

Diagnosed Sleep Apnea? YES NO (Advance to Sleep History)

On CPAP? YES NO

Dental Appliance? YES NO

Worn hours per night:

Number of days per week used:

Symptom Tracking With Active Treatment

Clinical Symptom Under Treatment	CPAP / Dental Appliance Option Response
Snoring with treatment
Apnea with treatment
Tiredness with treatment

Sleep History Profile Indicators

Symptom Evaluation	Response
Snoring
Breathing Pausing / Stopping
Gasp for breath
Cough/choke awake
Jerking/jumping of legs
Night sweats

Usual Bedtime:

Time required to fall asleep:

Typical nightly awakenings count:

What do you think wakes you up?

Refreshed upon awakening? YES NO

Usual rise time?

Headaches upon awakening? YES NO

Intentional napping? YES NO

If YES, times per week / length?

Daytime Tiredness Level

Airway, Clinical Comorbidities & Lifestyle Profile

Do you drive?

Do you experience any drowsiness while driving?

Family History: Asthma

Bronchitis/Emphysema/COPD

Other Family Problems

Nasal History (sinusitis/allergies/deviated nasal septum/congestion/surgeries)

Dental History (crowns/bridges/dentures/problems with bite/TMJ/dental surgeries)

Grind teeth at night?

Tonsils status

Have all teeth?

Dry Mouth on waking?

Mental Health (Suffering from depression or other psychiatric disorders recently?)

Previous Illnesses and/or Operations:

Current Active Medications

Name of Medication	Dosage / Strength	Times Per Day

List Medication Allergies

Weight changed last 3 years?

If YES, describe weight delta

Do you smoke?

Packs/day

Since Age

Do you drink alcohol?

Do you partake in recreational drugs?

Daily Stimulants & Caffeine Volumetric Intake Counts

Coffee

Tea

Cocoa

Cola/Soda

Chocolate

Epworth Sleepiness Scale (ESS) Evaluation

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times.
0 = would never doze | 1 = slight chance | 2 = moderate chance | 3 = high chance

Situation Matrix Scenario Description	Chance of Dozing
Sitting and reading	0 1 2 3
Watching TV	0 1 2 3
Sitting, inactive in a public place (theatre, meeting, etc.)	0 1 2 3
As a passenger in a car for an hour without a break	0 1 2 3
Lying down to rest in the afternoon	0 1 2 3
Sitting and talking to someone	0 1 2 3
Sitting quietly after lunch without alcohol	0 1 2 3
In a car, while stopped for a few minutes in traffic	0 1 2 3

Calculated Total ESS Score: / 24

Clinical Sleep Diary (7-Day Longitudinal Observation Block)

Complete the top rows in the morning immediately upon awakening, and tracking rows at the bottom in the evening before sleep.

Select Observation Week:

Metric Attribute Description	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Complete in the Morning
Time went to bed last night
Time woke up this morning
No. of hours slept last night
Number of awakenings
Total time awake last night
How long I took to fall asleep
How awake did I feel when getting up? (1-Wide awake, 2-A little tired, 3-Sleepy)
Complete in the Evening
Caffeinated drinks & times (coffee, tea, cola)
Alcoholic drinks & times (beer, wine, liquor)
Naptimes & lengths
Exercise times & lengths
How sleepy did I feel during the day? (1-Struggled, 2-Tired, 3-Alert, 4-Wide awake)

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