• assist with this questionnaire? Yes No Have you been to a sleep specialist before? Yes No Have you ever had a sleep study before? Yes No What is the highest gradeyou finished in school? Grades 1-8 Grades 9-11 High School/GED equivalent Junior College/Vocational Degree Some College (less than 4 years) College Degree.
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PHONE: (480) 830-3900 FAX: (480) 830-3901 valleysleepcenter.

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The questionnaire is meant to function as an alternative to the more time-consuming sleep diary format.

q I sleep alone. Scores on items belong to factors 2 and 5 (resto-ration after sleep and satisfaction with sleep) and are reversed before being tallied.

HEALTH HISTORY (check all that apply): Arthritis Chipped/loose teeth IV Device (port, PICC, etc.

Epworth Sleepiness Scale 11 How likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent.

. . Establish a "relax and wind down" routine (warm shower, drawing.

To answer these ques-tions, please consider both what others have told you AND what you know about yourself.

If all questions are answered, e-referral either approves or. May 25, 2023 · 3-29-96, FORM SHQ2 PAGE 3 OF 6. Please fill out the form completely.

Patient Patient’sfamily Sleep staff I. Do not get enough sleep.

The following questionnaire will help you measure your general level of daytime sleepiness.

The following questionnaire will help you measure your general level of daytime sleepiness.

The authors of the Cleveland Adolescent Sleepiness Questionnaire (CASQ) invite teachers, clinicians and researchers to use the measure and to share their findings so that the CASQ may be improved. Strive for a regular bedtime and rising time.

Patient Name: _____ Date: _____ Weekdays Usual bedtime: am/pm Usual awakening time: am/pm Weekends Usual bedtime: am/pm Usual. Consisting.

ciated with sleep disturbances, the PSQI was designed to evaluate overall sleep quality in these clinical populations.
Thank you for taking time to fill out the enclosed Sleep Habits Questionnaire.
Strive for a regular bedtime and rising time.

Johns, M.

Do not get enough sleep.

You are to rate the chance that you would doze off or fall asleep during different routine daytime situations. How often during the past 4 weeks did you (Circle One Number On Each Line) All of the Time W Most of the Time W A Good Bit of the Time W Some of the Time W A Little of the Time W None of the Time W 3. 8:.

. How often during the past 4 weeks did you (Circle One Number On Each Line) All of the Time W Most of the Time W A Good Bit of the Time W Some of the Time W A Little of the Time W None of the Time W 3. . My bedroom is q comfortable q noisy q too warm q too cold q es Y q No I have pets in the bedroom. To answer these ques-tions, please consider both what others have told you AND what you know about yourself. .

com Patient Name: DOB: Page 1 of 4 Sleep History Questionnaire Briefly describe your primary sleep complaint/problem:.

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How often during the past 4 weeks did you (Circle One Number On Each Line) All of the Time W Most of the Time W A Good Bit of the Time W Some of the Time W A Little of the Time W None of the Time W 3.

an accurate sketch of an individual’s typical sleep schedule, allowing sleep technicians to tailor the timing of polysomnographic studies to the pati-ent’s specifi c needs and habits.

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