SLEEP AND SNORING PROFORMA
Name
DOB
PRIMARY COMPLAINT
Describe your main sleep problem:
What one thing do you want to improve in your sleep symptoms?
How long have you had a sleeping problem?
Have you previously been diagnosed with a sleep problem? – if so what?
What investigations have you had (please detail where and when):
What treatments have you tried?
Sleep routine
Do you sleep alone?
Yes
No
WHAT TIME DO YOU GET INTO BED AND OUT OF BED?
Weekday
Got into bed Time:
Turned lights off Time:
Woke up Time:
Got out of bed Time:
Total time in bed
Estimated total time asleep (hrs)
Weekend
Got into bed Time:
Turned lights off Time:
Woke up Time:
Got out of bed Time:
Total time in bed
Estimated total time asleep (hrs)
How long does it take you to fall asleep?
<15mins
15-30mins
>30mins
Do you wake before your desired time?
How long before?
What is/are your routine/activities just before getting into bed? (For example I would wash dress and get into bed)
Do you do any of the following before bedtime:
Read / work or study in bed?
Eat a snack in bed?
Smoke before bedtime or on awakening in the night?
Watch TV in bed prior to sleep?
Drink alcohol before bedtime?
Have pets in the bedroom?
Symptoms of insomnia
Please tick the box if yes
Do you have trouble falling asleep?
Do you worry about falling asleep?
Do you have any thoughts that are preventing sleep?
How many times do you wake at night?
Approximately what times do you wake up?
How long do you stay awake? Duration
<10mins
<30mins
>30mins
What wakes you up?
Toilet
Hunger
Snoring
Partner
Children
Others :
How long does it take you to return to sleep
<15mins
>15mins
What keeps you awake in the night?
Yes
No
Do you have pain preventing sleep?
Yes
No
Breathing and nasal symptoms?
(people in your household can help you answer some of these)
Please tick box if yes
WHAT POSITION DO YOU SLEEP IN? ON SIDE / ON BACK / VARIABLE (BIT OF BOTH)
DO YOU SUFFER FROM a BLOCKED NOSE STOPPING YOU FROM SLEEPING? IF YOU HAVE A BLOCKED NOSE – IS IT DURING THE DAY / NIGHT / BOTH DAY & NIGHT
DO YOU HAVE A RUNNY NOSE / CATTARH / PHLEGM AT NIGHT?
DO YOU HAVE A CHANGE IN YOUR SENSE OF SMELL?
DO YOU HAVE ANY ALLERGIES TO CATS / DOGS / POLLEN / DUST MITE / other ?
DO YOU SNORE?
DO YOU STOP BREATHING AT NIGHT?
DO YOU GASP OR EXPERIENCE CHOKING OR COUGHING AT NIGHT?
DO YOU HAVE A DRY MOUTH AT NIGHT OR FIRST THING IN THE MORNING?
DO YOU HAVE NIGHT SWEATS?
DO YOU HAVE PALPITATIONS AT NIGHT?
DO YOU HAVE, INDIGESTION, HEART BURN OR ACID REFLUX?
DO YOU HAVE MORNING HEADACHES?
DO YOU HAVE SINUSITIS OR PAIN IN YOUR FACE OR TEETH?
DO YOU HAVE LOSS OF LIBIDO OR SEXUAL APPETITE?
Restless leg symptoms
Do you have uncomfortable sensory symptoms (tingling) in your legs which improve with movement?
Do you have an urge to move your legs when at rest, which is relieved by the movement?
Are the symptoms above worse in the evening?
Do your legs kick or jerk during the night?
Sleep behaviours
Do you have any episodes of sleep talking?
Beginning
middle
end
anytime?
Do you have any episodes of sleep walking?
Beginning
middle
end
anytime?
Does it occur more than once a night?
Do you have any episodes of disorientation on waking in the middle of the night?
Beginning
middle
end
anytime?
Do you have any episodes where on going to sleep or waking up in which you were unable to move, or feel paralysed?
Have you had any episodes on going to sleep or waking up during which you see your dreams or felt things whilst you are still awake? Do you act out dreams?
Beginning
middle
end
anytime?
Do you have any nightmares during the night?
Beginning
middle
end
anytime?
Vivid dreams on falling asleep or waking up?
Beginning
middle
end
anytime?
Do you wet the bed?
Do you have any episodes during the day of falling asleep?
Do you have any episodes of weakness triggered by emotion such as weak knees or head.
Do you dream during daytime naps?
DAYTIME SYMPTOMS
On awakening, do you feel
refreshed?
unrefreshed?
How long does it take you to feel alert?
When are you most alert?
Morning rather than evening?
Midday?
Evening rather than morning?
Do you feel sleepy when driving?
Have you had any accidents due to sleepiness
Do you take daytime naps
Yes
No
How many?
What time?
For how long?
Do you feel refreshed after nap
Yes
No
SOCIAL HISTORY – load onto the EPIC module
Do you drink caffeine containing drinks e.g. tea/coffee pepsi or cola
Yes
No
How many?
Time of last drink
How often do you exercise per week?
What line of the day?
Do you drink alcohol?
Units per week
Do you smoke?
Yes
No
Do you take any other drugs/ herbal remedies?
Yes
No
Occupation
Shift worker?
Yes
No
Do you travel across more than two time zones frequently?
Yes
No
CO-MORBIDITY
HIGH BLOOD PRESURE
STROKE
ANXIETY
ANGINA OR ISCHAEMIC HEART OR HEART RHYTHM PROBLEM
HEAD INJURY
DEPRESSION
HEART ATTACK
EPILEPSY
BIPOLAR DISORDER
HEART FAILURE
NEUROLOGICAL -OTHER
FIBROMYALGIA
ASTHMA
THYROID
CHRONIC FATIGUE SYNDROME
COPD
DIABETES
TEETH GRINDING
EMPHYSEMA
ENDOCRINE OTHER
OTHER MENTAL HEALTH ISSUES
RELATIONSHIP DIFFICULTIES / STRESS
WORK DIFFICULTIES / STRESS
PRE-MENSTRUAL SYNDROME
MENOPAUSE
PROSTATE PROBLEMS
HYPERCHOLESTEROLAEMIA
OTHER (please describe below)
PAST SURGICAL HISTORY
MEDICATION HISTORY
DRUG ALLERGIES
EPWORTH SCORE
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
FOR EACH SITUATION SELECT A NUMBER
0 = No chance of dozing
1 = Slight chance of dozing
2= Moderate chance of dozing
3 = High chance of dozing
It is important that you answer each question as best you can
SITUATION
CHANCE OF DOZING
WATCHING TV
SITTING AND READING
SITTING IN A PUBLIC PLACE (e.g. theatre or meeting)
AS A PASSENGER IN A CAR FOR AN HOUR WITHOUT A BREAK
LYING DOWN TO REST IN THE AFTERNOON WHEN CIRCUMSTANCES PERMIT
SITTING AND TALKING TO SOMEONE
SITTING QUIETLY AFTER LUNCH WITHOUT ALCOHOL
IN A CAR, WHILE STOPPED FOR A FEW MINUTES IN TRAFFIC
TOTAL SCORE
STANFORD SLEEPINESS SCALE
Please choose the statement that describes how you feel on an average day.
[ Please select only one rating option ]
Degree of sleepiness
Scale Rating
Feeling active, vital, alert, or wide awake
1
Functioning at high levels, but not at peak; able to concentrate
2
Awake, but relaxed; responsive but not fully alert
3
Somewhat foggy, let down
4
Foggy; losing interest in remaining awake; slowed down
5
Sleepy, woozy, fighting sleep; prefer to lie down
6
No longer fighting sleep, sleep onset soon; having dream-like thoughts
7
Asleep
8
Reflux Symptom index
Within the last MONTH, how did the following problems affect you?
0 = no problem 5 = severe problem
1. Hoarseness or a problem with your voice
0
1
2
3
4
5
2. Clearing your throat
0
1
2
3
4
5
3. Excess throat mucus or postnasal drip
0
1
2
3
4
5
4. Difficulty swallowing food, liquids, or pills
0
1
2
3
4
5
5. Coughing after you ate or after lying down
0
1
2
3
4
5
6. Breathing difficulties or choking episodes
0
1
2
3
4
5
7. Troublesome or annoying cough
0
1
2
3
4
5
8. Sensations of something sticking in your throat or a lump in your throat
0
1
2
3
4
5
9. Heartburn, chest pain, indigestion, or stomach acid coming up
0
1
2
3
4
5
TOTAL SCORE
Nasal Obstruction Symptom Evaluation (NOSE) Instrument
To the Patient :
Please help us to better understand the impact of nasal obstruction on your quality of life by completing the following survey. Thank You!
Over the past 1 month, how much of a problem were the following conditions for you?
Please tick the most correct response
Not a problem
Very mild problem
Moderate problem
Fairly bad problem
Severe problem
1. Nasal congestion or stuffiness
0
1
2
3
4
2. Nasal blockage or obstruction
0
1
2
3
4
3. Trouble breathing through my nose
0
1
2
3
4
4. Trouble sleeping
0
1
2
3
4
5. Unable to get enough air through my nose during exercise or exertion
0
1
2
3
4
Score
PSQI The following questions relate to your usual sleep habits during the past 30 days only. Your answers should indicate the most accurate reply for the majority of days and nights in the past 30 days. Please answer all questions.
1. When have you usually gone to bed at night?
2. How long (in minutes) has it usually take you to fall asleep each night?
3. When have you usually gotten up in the morning?
4. How many hours of actual sleep did you get at night?
(This may be different than the number of hours you spend in bed.)
For each of the remaining questions, check the one best response. Please answer all questions.
5. How often have you had trouble sleeping because you...
Not during the past 30 days
Less than once a week
Once or twice a week
Three or more times a week
(a) Cannot get to sleep within 30 minutes
(b) Wake up in the middle of the night or early morning
(c) Have to get up to use the bathroom
(d) Cannot breathe comfortably
(e) Cough or snore loudly
(f) Feel too cold
(g) Feel too hot
(h) Had bad dreams
(i) Have pain
(j) Other reason(s), please describe:
6. How would you rate your sleep quality overall?
Very good
Fairly good
Fairly bad
Very bad
7. How often have you taken medicine (prescribed or “over the counter”) to help you sleep?
Not during the past 30 days
Less than once a week
Once or twice a week
Three or more times a week
8. How often have you had trouble staying awake while driving, eating meals, or engaging in social activity?
Not during the past 30 days
Less than once a week
Once or twice a week
Three or more times a week
9. How much of a problem has it been for you to keep up enough enthusiasm to get things done?
No problem at all
Only a very slight problem
Somewhat of a problem
A very big problem
Score
Chart I — Hospital Anxiety and Depression Scale
This questionnaire will help your physician know how you are feeling. Read every sentence. Place an “X" on the answer that best describes how you have been feeling during the LAST WEEK. You do not have to think too much to answer. In this questionnaire, spontaneous answers are more important. Mark only one answer for each question.
A (1) I feel tense or wound up:
3
Most of the time
2
A lot of times
1
From time to time
0
Not at all
D (2) I still enjoy the things I used to:
0
Definetly as much
1
Not quite so much
2
Only a little
3
Hardly at all
A (3) I get a sort of frightened feeling as if something awful is about to happen:
3
Very definitely and quite badly
2
Yes, but not too badly
1
A little, but it doesn't worry mes
0
Not at all
D (4) I can laugh and see the funny side of things:
0
As much as i always could
1
Not quite as much now
2
Definitely not so much now
3
Not at all
A (5) Worrying thoughts go through my mind:
3
Most of the time
2
A lot of times
1
From time to time
0
Only occasionally
D (6) I feel chearful:
0
Most of the time
1
Usually
2
Not often
3
Not at all
A (7) I can seat at ease and feel relaxed:
0
Definetly
1
Usually
2
Not often
3
Not at all
D (8) I feel as i am slowed down:
3
Nearly all the time
2
Very often
1
From time to time
0
Not at all
A (9) I get a sort of frightened feeling like butterflies in the stomach:
0
Not at all
1
From time to time
2
Quite often
3
Very often
D (10) I have lost interest in my appearance:
3
Definitely
2
I don't take so much care as i should
1
I may not take quite as much care
0
I take just as much care as ever
A (11) I feel restless, as if i had to be on the move:
3
Very much indeed
2
Quite a lot
1
Not very much
0
Not at all
D (12) I lock forward with enjoyment to things:
0
As much as I ever did
1
A litle less than i used to
2
Definitely less than i used to
3
Hardly at all
A (13) 1 get a sudden feeling of panic:
3
Very often indeed
2
Quite often
1
From time to time
0
Not at all
D (14) I can enjoy a good TV or radio program or book:
0
Often
1
Sometimes
2
Not often
3
Hardly at all
Score
Please rate the current (i.e., last 2 weeks)
SEVERITY
of your insomnia problem(s).
None
Mild
Moderate
Severe
Very
1. Difficulty falling asleep
0
1
2
3
4
2. Difficulty staying asleep
0
1
2
3
4
3. Problem waking up too early
0
1
2
3
4
4. How
SATISFIED
/dissatisfied are you with your current sleep pattern?
Very Satisfied
Very Dissatisfied
0
1
2
3
4
5. To what extent do you consider your sleep problems to
INTERFERE
with your daily functioning (e.g., daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.)?
Interfering
A Little
Somewhat
Much
Interfering
0
1
2
3
4
6. How
NOTICEABLE
to others do you think your sleeping problem is in terms of impairing the quality of your life?
Interfering
A Little
Somewhat
Much
Interfering
0
1
2
3
4
7. How
WORRIED
/distressed are you about your current sleep problem?
Not At All
A Little
Somewhat
Much
Very Much
0
1
2
3
4
Guidelines for Scoring/Interpretation:
Add the scores for all seven items (questions 1 + 2 + 3 + 4 + 5 +6 + 7)
Your total score
Total score categories:
0–7 = No clinically significant insomnia
8–14 = Subthreshold insomnia
15–21 = Clinical insomnia (moderate severity)
22–28 = Clinical insomnia (severe)
Data collection grid
Question Group
Score
Epworth Sleepiness Score
Stanford Sleepiness Scale
STAMP
Reflux Symptom Index
SNOT 23
NOSE
Insomnia Severity Index
Hospital Anxiety
Depression Scale
IRLS
Pittsburgh Sleep Quality index
BMI
Respiratory SLEEP STUDY DATA
AHI
RDI
ODI
Flow
Snore
CLINICAL INVESTIGATIONS
NIPF
SPT
Ferritin levels
SURGICAL INVESTIGATIONS
PTLB (VV)
Croft / Pringle
VOTE
TOTAL
