Sleep Health History

1. Are You Experiencing Any Of The Following?

2. What Are The Chief Complaints For Which You Are Seeking Care? Please Order Complaints By Number (1 = Most Important, 10 = Least)

3. Please List Other Health Providers You Are Currently Seeing

4. The Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is asimple, self-administered questionnaire that is widely used by sleep professionals in quantifying the level of daytimesleepiness.

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to yourusual way of life at present and in the recent past. Even if you have not done some of these things recently, try to workout how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze

5. Please Indicate Any Medications/Substances Which Have Caused An Allergic Reaction

6. Please List All Medications Currently Being Taken

7. Please Update The Following Medical/Dental History

I Certify That The Above History Is True And Correct To The Best Of My Knowledge