SLEEP DISORDER COMORBIDITY FORM

1. Do you have any kind of LUNG or AIRWAY problem?
Yes No

2. Do you have any kind of HEART FAILURE?
Yes No

3. If you DO have any kind of heart failure, how much activity makes you short of breath or fatigued:

Exercise
Walking more than 300 feet
Walking less than 300 fee
Sitting still

4. Do you have any difficulty breathing when laying down flat on your back (while awake)?
Yes No

5. Unusual swelling around your ankles?
Yes No

6. Unexpected weight gain from retaining fluid?
Yes No

7.Do you have any kind of HYPOVENTILATION problem?
Yes No

8. Do you regularly take any kind of opiate/opioid pain medication?
Yes No

10. How many alcoholic drinks do you regularly have in the evening?

11. Do you have any neuromuscular disorder?
Yes No

12. Do you regularly take any kind of sleeping medication?
Yes No

13. Do you take any benzodiazepine (perhaps for anxiety) in the evening on a regular basis?
Yes No

14. Do you take any kind of muscle relaxer in the evening on a regular basis?
Yes No

15. If you were to exercise substantially, would you become short of breath?
Yes No

16. Do you have swelling around your ankles?
Yes No

17. Do you often wake up in the morning with a headache?
Yes No

18. Do you have chest tightness?
Yes No

19. Is it often difficult for you to think clearly?
Yes No

20. Do you have any cardiac arrhythmia (abnormal heart rhythm)?
Yes No

21. Do you have polycythemia (high number of red blood cells)?
Yes No

22. Do you have any kind of CENTRAL SLEEP APNEA?
(Note that CENTRAL sleep apnea is not OBSTRUCTIVE sleep apnea) (CENTRAL sleep apnea is when the brain fails to send signals to the diaphragm & lungs to breathe)
Yes No

23. Do you have heart failure?
Yes No

24. Atrial fibrillation?
Yes No

25. Atrial flutter?
Yes No

26. Cheyne-stokes breathing pattern?
Yes No

27. Have you ever had a stroke?
Yes No

28. Do you have any neurological condition?
Yes No

29. Do you have arnoldchiari syndrome?
Yes No

30. Do you have any condition in the “brainstem” area?
Yes No

31. Do you regularly take any opiate/opioid pain medication?
Yes No

32. Do you NOT snore?
Yes No

33. Do you ever have an unusual breathing pattern WHILE AWAKE?
Yes No

34. Has a bed partner ever noticed you having any breathing issues WHILE ASLEEP?
Yes No

35. Do you have trouble falling asleep within 30 minutes on a regular basis?
Yes No

36. Do you have trouble falling BACK asleep within 30 minutes (after you’ve awoken) on a regular basis?
Yes No

37.Do you frequently have neck pain, dizziness, and headache?
Yes No

38. Do you frequently get a headache from laughing or coughing or exerting yourself?
Yes No

39. Do you have unusual weight loss or night sweats?
Yes No

40. Do you have fevers (measured with a thermometer) without having a good reason for the fever (like the flu or a stomach bug infection)?
Yes No

41. Do you have PERIODIC LIMB MOVEMENT DISORDER?
Yes No

42. Has a bed partner ever said you are a restless sleeper (or move around a lot while asleep)?
Yes No

43. Do you find your bedsheets in disarray when you wake up?
Yes No

44. Do you have trouble falling asleep within 30 minutes on a regular basis?
Yes No

45. Do you have trouble falling BACK asleep within 30 minutes (after you’ve awoken) on a regular basis?
Yes No

46. If so, do these things happen to you at least 3 nights per week?
Yes No

47. Has this been going on for more than 3 months?
Yes No

48 .Do you have significant NASAL CONGESTION
Yes No

49. Do you frequently have nightmares?
Yes No

50. Do you sometimes have episodes of waking up and being unable to move or speak for a short period of time?
Yes No

51. Has a bed partner ever thought you were “acting out your dreams” because of the movements you were performing while asleep?
Yes No

52. Do you sometimes do “sleepwalking” (as an adult, not as a child)?
Yes No

53. Do you think you have ever eaten anything or tried to prepare food while sleepwalking?
Yes No

54. Do you sometimes lose your urine while asleep in bed?
Yes No

55. Do you ever see dream imagery while you are still awake, but in the process of falling asleep?
Yes No

56. Do you ever see dream imagery while you are in the process of waking up from sleep?
Yes No

57. Has a bed partner ever said you sometimes wake up confused, then fall back asleep, but you don’t remember it the next day?
Yes No

58. Do you ever jump out of bed with severe anxiety and shouting (which you don’t remember the next day) and during which family members find it hard to console you, and even find it hard to wake you up (or “shake you out of it”)?
Yes No

59. If any of the events in the above NON-REM PARASOMNIA section (starting with “sleepwalking as an adult”) have happened to you, did they occur in the first one-third of the night (in the first 2-3 hours of you being asleep)?
Yes No

60. Do you have any NEUROMUSCULAR DISORDER?
Yes No

61. Have you ever had any kind of SIGNIFICANT HEAD INJURY or SPINAL CORD INJURY?
Yes No

63. Do you SNORE?
Yes No

64. Are you TIRED often?
Yes No

65. Has anyone OBSERVED you having breathing issues while asleep?
Yes No

66. Do you have high blood PRESSURE?
Yes No

67. Is your BMI 35 or higher?
Yes No

68. Is your AGE 50 years or older?
Yes No

69. Is your NECK circumference 40 centimeters or greater?
Yes No

70. Is your GENDER male?
Yes No

71. During each 24 hour cycle, do you typically always sleep during the same time period or same “time block” (such as the time block from 11.00 pm until 7.00 am)?
Yes No

72. In general, how many total hours of sleep do you get each night?

73. In general, how many hours do you nap each day?

74. Have you ever had a car accident (or “near miss”) from briefly dozing off while driving? Have you ever fallen asleep driving?
Yes No

75. Do you ever experience genuine paralysis (a complete loss of muscle strength) anywhere in your body (face, neck, knees, or anywhere else) -- AND that genuine paralysis seems to be triggered by sudden emotion (like laughter, surprise, or anger) or when hearing a joke or telling a joke?
Yes No

This loss of muscle strength may be subtle, and others may be aware of it even if you are not HERE ARE SOME EXAMPLES:
Loss of strength in your head or neck -- resulting in some head drop
Loss of strength in your face or jaw -- resulting in sagging of your face or jaw, or eyelid drooping, or loss of facial expression, or even difficulty speaking clearly
Loss of strength in your knees or legs -- resulting in a gradual fall

76. Have you ever woken up but found yourself unable to move or speak?
Yes No

77. Do your arms or legs move around (by themselves, unintentionally) while you are asleep?
Yes No

78. For many years have you consistently (nearly every night) had trouble falling asleep before midnight or even before 6.00 am?

79. For years have you consistently (nearly every night) had trouble staying awake past 8.00 pm? If so, at what age did this begin?

80. Do you have (or have you had in the past) any of the below listed conditions:

Heart attack
Stroke or TIA (mini-stroke)
Atrial fibrillation or other cardiac arrhythmia (abnormal heart rhythm)
CHF (congestive heart failure)
Cor pulmonale (right sided heart failure)
Hypertension or Pulmonary hypertension (high blood pressure in the lungs specifically)
Diabetes

81. OSA (Obstructive Sleep Apnea)?
Yes No

82. If so, do you use CPAP to treat it? If so, what is the CPAP pressure setting?
Yes No

83. When was your last sleep study? Over 5 years ago?