Dr. Darrell Morden

1107-37th St. SW Calgary, AB T3C 1S5

(403) 242-5777

Sleep Questionnaire for Diagnosed Sleep Apnea Patients

Dr. Darrell Morden DDS Diplomate, American Board of Dental Sleep Medicine

PLEASE SET ASIDE TIME TO COMPLETE THIS FORM ACCURATELY

Date

How did you hear about Our Clinic?

Google Ad Internet Search Doctor Referral Friend Referral Existing patient Other:

PERSONAL INFORMATION

Mr. Ms. Mrs. Dr. First

Last

Phone

Date of Birth:

Age:

Best Tele Number:

Home Address:

Family Physician/Walk-in:

AHS Care #:

Family Dentist/Clinic:

Specialist Doctors:

Pharmacy:

As applicable

we may request and review a CPAP compliance report or sleep record from physician (if applicable)

we have provided you our privacy agreement/ medical authorization form

CHIEF COMPLAINTS / REASONS FOR CONSULTATION

Snoring / Loud

Snoring affects sleep of others

Bed partner separation

Daytime drowsiness

Fell asleep driving / at work

Causing problem at work

Unrefreshing sleep

Interrupted sleep

Awakening from sleep

Unable to sleep on back

Choking/gasping in sleep

Witnessed stopped breathing

Difficulty falling asleep

Difficulty staying asleep

Waking short of breath

Morning hoarseness

Morning headaches

Morning fogginess

Memory / concentration

Depression/anxiety

Insomnia

Feeling tired / low energy

Losing appetite / or over-eating

Restless legs / limb movement's

Problem with other therapy attempts (eg. CPAP, weight loss programs, nasal rinse, snore guards, etc)

Sleep bruxism/grinding/clenching

SLEEP CENTRE EVALUATION(S)

Previous Sleep Clinic or Sleep Physician evaluation(s)?

Yes No

If yes, list Clinic/Doctor

Year

Overnight study

Home In-Lab

Diagnosis List

Sleep Apnea Mild Moderate Severe Night-time Oxygen problem Snoring

Insomnia Restless Legs / limb movemt’s Parasomnias (sleep walking) Narcolepsy

If an ENT / Surgeon consulted for sinus/airway concerns? Name

Previous Insomnia / Cognitive-behavioral interventions?

Yes No

Where:

DAYTIME SLEEPINESS PROBLEMS (EPWORTH SLEEPINESS SCALE)

How likely are you to doze off or fall asleep in the following situations?

(Even if not a recent thing, think on how they would have affected you in these specific examples)

0=No Chance, 1=Possibly, 2=Would have, 3=Yes definitely

Sitting and reading 0 1 2 3

Watching TV / Movie 0 1 2 3

Sitting inactive (Meeting, Theatre) 0 1 2 3

As a passenger a car for an hour 0 1 2 3

Lying down to rest in the afternoonpermit 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quiet after lunch, no alcohol 0 1 2 3

In a car, stopped in traffic 0 1 2 3

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Date

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I acknowledge that I have been made aware of the reasons for the disclosure of the above information, and the risks and benefits associated with consenting or not consenting to its release.

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Telephone Number

Alcoholic beverage	Daily	Weekly	Rarely	Never	Before Sleep	Problematic	History
Caffeine beverage	Daily	Weekly	Rarely	Never	Before Sleep	Problematic	History
Nicotine/replacement	Daily	Weekly	Rarely	Never	Before Sleep	Problematic	History
CBD/THC/Marijuana	Daily	Weekly	Rarely	Never	Before Sleep	Problematic	History
Evening consumption	Alcohol	Caffeine	Nicotine	CBD/THC	Food

Sleep Questionnaire for Diagnosed Sleep Apnea Patients

SLEEP CENTRE EVALUATION(S)

Diagnosis List

THERAPY ATTEMPTS

CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE) HISTORY

CPAP INTOLERANCE / PROBLEMS

SLEEP HISTORY / NORMAL HABITS

Awakenings/Interrupted sleep caused by: