Sleep Interview Questionnaire
Name: Gender: Date of Birth:
Marital Status: Age: ____ yrs. Education Level:
Referral source: Interviewer:
Section #1
Nature of sleep problem
Do you have issues falling asleep on a typical night? Mild Average Severe No
Answer: Severe
Do have trouble waking up in the morning? Mild Average Severe No
Answer: No
Do you have trouble staying asleep (day or night)? Mild Average Severe No
Answer: Mild
Do you have difficulty sleeping during the day? Mild Average Severe No
Answer: No
Do you have trouble staying awake during the day? Mild Average Severe No
Answer: Average
Most people with a sleeping disorder report experiencing trouble sleeping equally during the day and at night, as an interviewer have you found this to be true as well?
Which of the following do you experience after a poor night’s sleep?
Sleepiness: Yes_ No__ Daytime fatigue Yes_ _ No__ Moodiness: Yes _ _ No __
Poor Concentration: Yes __ No __ Physical symptoms (muscle pains, headache): Yes __ No
What do you usually do in bed before you sleep? (For instance reading or praying)
Answers: Most of the time I watch TV or listen to music, but occasionally I also read a book.
What sort of things makes it longer to fall asleep such as noises or thoughts?
Answers: Usually any slight movement or change in temperature or emotional instability will cause me to spend hours before fall asleep.
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After falling asleep do you wake up during the night? If so how often and for how long?
Answer: After falling asleep I am only asleep for 2hours continuously after which I wake up and stay awake for long hours.
Do you have a bed partner? How is their sleeping habit like? Are they heavy sleepers?
Answer: Yes I do, she is a fast sleeper, she will fall asleep before I do, and sleep till morning on a typical night without disturbance.
Section #2
Question #1
On a typical night, do you snore at night or has your bed partner complained that you snore at night?
I have not known myself to snore in my life before, but recently I heard complaints from my bed partner that I am snoring a lot at night making her uncomfortable.
Question #2
Do you experience shortness of breath at night?
Yes, I regularly do, but I always assume that I was sleeping in a bad position and hence I adjust myself and go back to sleep.
Question #3
During the day do you experience morning headaches or feeling sleepy during the day?
The headaches are infrequent, and I rarely sleep during the day due to the nature of my work, although at times I have been accused of losing concentration at work.
Question #4
Do you experience chest pains when you sleep either during the day or at night?
Yes I do and have sought medical attention, but the chest pains remain persistent
Question #5
Have you or your bed partner noticed any random pauses in your breathing while sleeping?
In essence, I do not sleep much at night, and my bed partner sleeps through the night, so I would not confirm or deny this since I do not have the facts.
Name of the Disorder: Sleep Apnea
Reasons the Five Specific Questions Were Selected
Primarily, in case the answers to these questions were definite, these would indicate symptoms of Sleep Apnea (Pascualy, 2010). Consequently, these questions were selected with an aim of disqualifying or confirming the existence of sleep condition. Apparently, the patient may not be aware that specific symptoms are related to sleep complications and hence focuses on treating individual symptoms such as headaches only while the underlying problem remains hidden (Sleep Apnea FAQs - Answers To Your Questions | American Sleep Assoc, 2018). Additionally, inquiring on the opinion of bed partners may provide information new to the patient and the study entirely.
The Type of Information That the Questions at hand tends to help Obtain Complementary Information to the Ones Gained during the Study
The information collected from these questions is meant to elaborate on the cause of some of the symptoms that the interviewee has reported to experience. It may also reveal possible medication use prescribed to the patient or purchased over the counter following prior diagnosis. Additionally, the doctor can explain in clear details why and for what the patient is being tested for (Pascualy, 2010). Consequently, the doctor understands who found out the problem, whether it was the bed partner or even the workplace or possibly the patient himself. In this light, the doctor will be able to make the correct interpretations of the study.
References
Pascualy, R. (2010). Snoring and sleep apnea . [Australia]: Read HowYouWant.
Sleep Apnea FAQs - Answers to Your Questions | American Sleep Assoc. (2018). Retrieved from https://www.sleepassociation.org/sleep-disorders/sleep-apnea/sleep-apnea-faqs/
