281.296.6797
1.866.TMJ.TEXAS		 1001 Medical Plaza Dr. Suite 200
The Woodlands, Texas 77380
 




 

Sleep Questionnaire

Should you seek treatment for your snoring, fatigue or other sleep related concerns?

 

Fill out the easy questionnaire below and Dr. Prehn will evaluate your symptoms. 

Patient Information

First Name*
Last Name*
Phone*
Mobile Phone
Email*

Describe your chief concern regarding your sleep:

(ie) snoring, fatigue...
Have you ever had a sleep study?
List the sleep medications you have taken in the last year (include nonprescription):

Please answer the the following questions as they apply to your sleep habits:

Do you snore?
Do you have or have you ever had the following?
What is your usual sleep position?
How long does it take you to get to sleep at night?
Number of average hours you sleep per night:
Number of times you wake up during the night:
Length of time it takes you to get back to sleep when awoken at night:
How many caffeinated beverages do you have each day?
Check the following questions that pertain to you:
Check any of these additional health issues that apply to you:
Does your bed partner complain of:

Rank how likely it would be for you to become drowsy during the day in the following situations:

Sitting and Reading
Watching TV
Sitting inactive in a public place (i.e. theater)
As a car passenger for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, stopped for a few minutes in traffic

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