SRN web-education committee members identified commonly used and validated questionnaires that are relevant to research and clinical practice of both adult and pediatric Sleep Medicine. THE EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? , bunk bed, bed with rails etc. docx Created Date:Z. For each problem, please list the date it started and whether or not it is still present. I have trouble falling asleep sleep questionnaire pdf at night.
If eight or more statements are answered “yes”, consider referring for sleep evaluation CHERVINE ET AL, PEDIATRIC SLEEP QUESTIONNAIRE: VALIDITY AND RELIABILITY OF SCALES FOR SLEEP DISORDERED BREATHING, SNORING, SLEEPINESS, AND BEHAVIORAL PROBLEMS, SLEEP pdf MEDICINE ;1:21-32. q I share a bed with someone. STOP-BANG Sleep Apnea Questionnaire Chung F et al Anesthesiology and BJA STOP. Please list any sleep disorders diagnosed or suspected by a physician in your child. Do you grind your teeth while you sleep? Child’s Sleep Habits Questionnaire (pre-school and school-aged children) The following statements are about your child’s sleep habits and possible difficulties with sleep. , odor, humidity etc. The information you provide is very important and will assist the sleep specialist during the review of your sleep symptoms.
Agnes Hospital, Fond du Lac, WI SLC/15/13) ORDER FROM PRINTING Page 8 of 9. Head Office Shop 4, 80 Walkerville Terrace Walkerville SA 5081 Tel:Fax:Email: com OSA-50 Screening Questionnaire The OSA-50 Screening Questionnare pdf is used to screen for Obstructive Sleep Apnoea (OSA) and assesses sleep questionnaire pdf if you are at risk for Sleep Apnoea. When you have your total score, look at the &39;Guidelines for Scoring/Interpretation&39; below to see where your sleep difficulty fits. SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. This questionnaire is for patients 13 years of age or older who have a.
Please sign each page. Date:_____ sleep questionnaire pdf SLEEP QUESTIONNAIRE. CHILDREN’S SLEEP HABITS QUESTIONNAIRE (ABBREVIATED) The following statements are about your child’s sleep habits and possible difficulties with sleep.
Think about the past week in your life when you answer the questions. . Therefore, if possible, please complete this questionnaire with sleep questionnaire pdf the help of someone who can comment on what you do when you are asleep (i. Ask if they go to bed at 8 pm only to find out sleep questionnaire pdf that they wake up at 3 am (Advanced Phase Syndrome—more common in the elderly). Insomnia sleep questionnaire pdf Severity Index The Insomnia Severity Index has seven questions. 3-4 times per week c. Thank you for helping us to take better care of you. If yes, how sleep questionnaire pdf many nights per week do you experience insomnia due to the hot flushes?
Do your arms or legs jerk/kick in your sleep? Grind your teeth at night. ) (E) Other Is there anything else about the child’s ambient sleep environment that can influence his or her sleep? To assist in determining the sleep questionnaire pdf source of sleep questionnaire pdf any problem, please take your time and. What type of bed does the child sleep in (e. LABEL BED PARTNER QUESTIONNAIRE. Date:_____ SLEEP QUESTIONNAIRE.
Even if you have not done some of these activities recently, try to work out how sleep questionnaire pdf they. at the Sleep Center. Almost every day b. Jupiter Medical Center - Sleep Questionnaire 1025 Military Trail, Suite 210, Jupiter FLFaxEmail: Microsoft Word - ESHT-epworth-sleepiness-scale. It will take approximately 15 to 20 minutes to complete. Microsoft sleep questionnaire pdf Word - Sleep_Questionnaire. For this questionnaire, the word “usually” means “more than half the time” or “on more than half the nights.
. The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in adult sleep questionnaire pdf s. Keywords: Sleep, Intensive Care Unit, Psychometrics, Richard Campbell Sleep Questionnaire 1. ) What is the mattress quality? doc Author: tothr Created Date:Z. , could it cause discomfort? 1-2 times per week d. I often have frightening dreams.
Wake up in the middle of the night to eat. SLEEP QUESTIONNAIRE FOR ADULTS and children aged 11+ years Some of the questions in this questionnaire ask about things sleep questionnaire pdf that may happen whilst you are asleep (and of which you yourself would be unaware). Please complete the following information: 1.
The Epworth Sleepiness Scale The Epworth Sleepiness Scale is widely used in the field of sleep sleep questionnaire pdf medicine as a subjective measure of a patient&39;s sleepiness. Have you ever walked or talked in your sleep? 2-3 sleep questionnaire pdf am) and sleep in until noon (Delayed Sleep sleep questionnaire pdf Phase—more common in adolescents).
See page 2 pdf for guide to interpreting the questionnaire. Walk in your sleep. 1-2 times per month e. Eat in your sleep. Please list any psychological, psychiatric, emotional, or behavioral problems diagnosed or. It differentiates “poor” pdf from “good” sleep quality by measuring seven areas (components): subjective sleep quality, sleep sleep questionnaire pdf latency, sleep. Do you have frequent nightmares?
Even if you have not done some of these things recently try to work out how they would have affected you. q es Y q No I watch TV in bed prior to sleep. I often take sleeping pills in order to sleep. This refers to your usual way of life in recent times. The sleep questionnaire pdf seven answers are added sleep questionnaire pdf up to get a total score. My bedroom is q comfortable q noisy q too warm q too cold q es sleep questionnaire pdf Y q No I have pets in the bedroom. SLEEP QUESTIONNAIRE Center for Sleep Disorders St.
Act out your dreams pdf (punching, kicking, fighting, etc. Even if you haven’t done some of these things recently, try to work out how they would have affected you. Microsoft Word - Sleep Questionnaire UPDATED. The test is a list of eight situations in which you rate your tendency to become sleepy on a scale of 0, no chance of dozing, to 3, high chance of dozing. , 1994) was derived from the Sleep Questionnaire and Assessment of Wakefulness or "SQAW" (Miles, 1982) in an attempt to provide such a triage tool.
Phone:(578) 365-8393 x 3845