Patient Form Submission6. History of Present IllnessPlease complete all applicable fields. An asterisk (*) indicates a required field. Name * First Name Last Name Gender * Female Male Other Height in inches * 4 feet = 48 inches, 5 feet = 60 inches, 6 feet = 72 inches Weight in pounds * Neck circumference Chief complaint * Please enter the reason for consultation Sleep History Prior sleep evaluation If you've had a prior sleep evaluation, please provide details below (where, when, what tests were done, diagnoses given, etc.). If no prior evaluation, then enter "N/A" or leave blank. Bedtime * What time do you typically get into bed. NOTE: This is NOT when you estimate you fall asleep. This is when you physically get into your bed. If this is variable, do your best to pick one time. You'll have a chance to explain below. (You can leave the seconds blank. Midnight is 12:00 AM and noon is 12:00 PM.) Hour Minute Second AM PM Rise time * What time do you typically get into bed. NOTE: This is NOT when you estimate you wake up. If this is variable, do your best to pick one time. You'll have a chance to explain below. (As above, you can leave the seconds blank.) Hour Minute Second AM PM Sleep onset latency * How long does it typically take you to fall asleep once you start trying to sleep, in minutes. Arousals * How many times do you typically wake up in a given night. If it's variable, do your best to estimate a single number. WASO * In minutes, estimate how much time you spend awake during the night total, but do not include the time it takes to fall asleep initially. Nap frequency * Typically, how many days per week do you nap? (Enter 0 if this occurs less than once per week.) Nap duration * In minutes, how long is a typical nap. If this varies, do your best to estimate a single number. Nap dreams * Do you dream during naps? Yes No Nap restoration * Are naps restful? Yes No EDS * Are you sleepy/tired most days? Yes No Abnormal Movements RLS * Do you experience uncomfortable/restless sensation in your legs when sitting or lying down? Yes No RLS resolution If you answered yes to the above question, does moving your legs briefly calm the sensation? Yes No N/A RLS frequency If you answered yes to the question about RLS, how often do you get these sensations? Never or N/A Less than once per month 1-2 times per month Once per week 2-3 times per week 4-6 times per week Every day PLMS * Have you been told/experienced kicking/twitching in your legs while sleeping? Yes No RBD * Do you ever act out your dreams? Yes No/unsure RBD frequency * If you have episodes of acting out your dreams, how often does this occur? Never or N/A Less than once per year 2-3 times per year 3-6 times per year Once per month 2-3 times per month Once per week More than once per week Dream content * Do you have frequent violent/disturbing dreams? Yes No Sleep paralysis * Do youever wake up out of sleep and are completely paralyzed? (This does not mean too tired to move. This means you physically cannot move.) Yes No Cataplexy * Do you ever experience sudden brief loss of muscle strength during the day following an emotion (e.g., laughter or anger)? Yes No Bruxism * Do you clench and/or grind your teeth in your sleep? Yes No Abnormal respirations during sleep Snoring * Do you snore during sleep? Yes No Snoring severity * Is your snoring loud enough to be heard through closed doors or cause your bed partner to elbow you? Yes No Apnea * Have you been observed to stop breathing or choke/gasp during sleep? Yes No Thank you!