CQRASC Sleep History Form "*" indicates required fields Patient InformationFirst Name* First Surname D.O.B* DD slash MM slash YYYY Age*Gender* Male Female Other Collar SizeWeightHeightSmoking* Yes No If yes, Age StartedNumber a DayAlcohol* Yes No Spirits / LagerNumber a WeekDriving* Yes No Type of LicenseCurrent ProblemsCough* Yes No Chest Pain* Yes No Wheeze* Yes No Breathlessness* Yes No Weight Loss* Yes No Back Pain* Yes No Night Sweat* Yes No Coughing Blood* Yes No Existing Medical HistoryAsthma* Yes No COPD* Yes No Diabetes* Yes No Hypertension* Yes No Heart Problems* Yes No Acid Reflux* Yes No Anxiety/ Depression* Yes No Others (Including Surgeries / Previous Cancers)Current Medications (Including Over the Counter Treatment)AllergiesAllergiesESS: Daytime Sleepiness Questionnaire How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling 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. Choose the most appropriate number for each situation. Sitting and Reading* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Watching TV* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Sitting, inactive in a public place (eg. theatre or a meeting).* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing As a passenger in a car for an hour without a break.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Lying down to rest in the afternoon when circumstances permit.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Sitting talking to someone.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Sitting quietly after a lunch without alcohol.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing In a car, while stopped for a few minutes in traffic.* 0. Never Doze 1. Slight Chance of Dozing 2. Moderate Chance of Dozing 3. High Chance of Dozing Please complete questions below Do you snore loudly and persistently as reported by partner?* Yes No Do you wake feeling tired or feel sleepy during the day?* Yes No Waking with a headache?* Yes No Have you ever woken choking / gasping or has anyone ever seen you stop breathing while asleep?* Yes No Vivid Dreams / Nightmares?* Yes No Poor concentration / reduced cognitive function?* Yes No Frequent night time urination (Nocturia)?* Yes No Teeth Grinding (Bruxism)?* Yes No Do you suffer from Insomnia?* Yes No Reduced libido / erectile dysfunction?* Yes No Date* DD slash MM slash YYYY
