What time do you usually go to bed on weekdays?__________________am or pm 2 What time do you usually get up on weekdays?_____________________am or pm What time do you usually go to bed on weekends?__________________am or pm What time do you usually get up on weekends?_____________________am or pm How do you usually awaken? Spontaneously? Y N Alarm Clock? Y N Other? (Explain)______________________________________________________ Do you have difficulty getting to sleep when you want to? Y N How long does it take to get to sleep?___________________________min or hr. Do you do anything to try to make yourself get to sleep? Y N If yes, what?_________________________________________________________ ___________________________________________________________________ Have you taken any types of pills or substances to try to get to sleep? Y N If yes, what?_________________________________________________________ ___________________________________________________________________ Is it harder to get to sleep on certain days? Y N What do you do to get ready for bed/sleep?_________________________________ Do you eat meals or snacks shortly before bedtime? Y N Do you consume any of the following before bedtime: Alcohol? Y N Sleeping pills? Y N Antihistamines? Y N Other sedatives? Y N Do you have restless, crawling feelings in your legs when you lie down? Y N Do you get more AWAKE after getting in bed? Y N Do you snore? Y N IF YES: Is it considered loud by others? Y N How often do you snore?_________________________________________ How long have you had snoring?___________________________________ What do other people say about your snoring?_________________________ Do others prefer to sleep elsewhere because of your snoring? Y N 3

Do others say you stop breathing when you are asleep? Y N If yes, how often? _______________________________________________ Is your snoring interrupted by silent periods, gasping, coughing, choking or snorting sounds? Y N Do you wake yourself up with snoring? Y N Do you notice anything about your own snoring or breathing during sleep? Y N If yes, what have you noticed?_____________________________________ Do you breathe with your mouth open while asleep? Y N Are you aware of any awakenings during your sleep hours? Y N Do you feel you have trouble staying asleep when you want to? Y N How many times a night, on average, do you awaken during your sleep hours? ________________times per night. Can you ever tell what has awakened you? Y N If yes, what have you noticed?____________________________________________ Do you have heartburn day or night? Y N If yes, how often?______________________________________________________ Do you awaken with sour/acid taste or liquid in your throat/mouth? Y N If yes, how often?_____________________________________________________ Do you awaken to go to the bathroom? Y N If yes, how often? _____________________times per night. Do you ever wet the bed? Y N Do you have coughing episodes during your sleep? Y N Is noise in the house or outside occurring during your sleep? Y N Do you awaken with excessive sweat over your hair, head, or neck? Y N If yes, when did it start happening?________________________________________ Do you awaken with headaches? Y N 4

If yes, when did they start?______________________________________________ Do others say you have jerking of your legs during your sleep? Y N Do you awaken with any choking or other shortness of breath sensations? Y N If yes, how often?______________________________________________________ What do others tell you about awakenings during your sleep time?_________________ _____________________________________________________________________ After awakenings, how long does it usually take to get back to sleep? _____________________min or hours Do others say you have restless sleep generally? Y N Do you walk in your sleep? Y N If yes: What time does it tend to occur?_____________________________________ How many nights a week does it occur?_______________________________ When did it start?________________________________________________ Do you remember dreams/thoughts connected to sleepwalking? Y N Have you ever been injured during sleepwalking? Y N Do you talk in your sleep? Y N How much sleep do you actually get during your regular sleep hours?__________hrs Do you feel well-rested after getting up? Y N How long does it take you to feel alert and functioning after sleeping?_____________ Do you feel confused when you awaken? Y N If yes: When did it start?_______________________________________________ How long does it last?____________________________________________ Do you feel you get TOO MUCH sleep during your regular sleep hours? Y N Do you feel you get TOO LITTLE sleep during your regular sleep hours? Y N Do you have any trouble staying awake when you need to be awake? Y N 5 Do you have excessive tiredness or fatigue when you need to be awake? Y N

Is sleepiness/tiredness predictable? Y N Do you find yourself falling asleep when you don’t mean to? Y N Does sleepiness or tiredness interfere with your work performance? Y N Do you fall asleep during any of the following: Watching TV? Never Rarely Sometimes Frequently Sitting down briefly? Never Rarely Sometimes Frequently While at work? Never Rarely Sometimes Frequently After lunch? Never Rarely Sometimes Frequently In public? Never Rarely Sometimes Frequently Reading books/newspapers? Never Rarely Sometimes Frequently If fall asleep frequently with reading, please specify (circle): 1/wk 2/wk 1/day 2-3/day 4-5/day >5/day Have you ever fallen asleep in any embarrassing situation, such as with your employer, or other? Y N If yes, give details:_____________________________________________________ ____________________________________________________________________ Have you ever fallen asleep, even briefly, while driving? Y N If yes, give details of when, where, why, and what happened as a result:___________ ____________________________________________________________________ ____________________________________________________________________ Have you ever fallen asleep in any other type of dangerous situation in which you or others were injured or could have been injured as a result of your falling asleep? Y N If yes, give details of when, where, why, and what happened as a result:___________ ____________________________________________________________________ ____________________________________________________________________ Are there any other circumstances in which you fall asleep when you do not intend to? Y N If yes, describe:_______________________________________________________ ____________________________________________________________________ Have you had lapses of concentration while driving 6 which led to any accident or near accident? Y N

Do you feel more alert after any unintentional sleep? Y N Do you take planned naps during your waking hours? Y N If yes: How often?____________________________________________________ How long are the naps?__________________________________________ Do you feel better after taking a planned nap?_________________________ Have you taken any type of pills or substances to try to stay awake? Y N If yes, what?__________________________________________________________ Do others say you are getting irritable or short-tempered? Y N Do you experience dreams seeming to start before you are fully asleep? Y N Do you have dreams in even brief naps? Y N In the context of experiencing an emotion, such as anger, fright, laughter, have you felt that your muscles got weak in any way? Y N Have you experienced feeling paralyzed while “half-asleep” or unable to move when going to sleep or waking up? Y N Have you experienced seeming to hear people or noises, and felt uncertain whether they were real or not, while going to sleep, waking during sleep, waking up after sleep, or during the day? Y N Do you have any history of: Head injury? Y N Nose injury? Y N Neck/throat injury? Y N Tonsillectomy? Y N Adenoidectomy? Y N Any other head/neck surgery? Y N Any history of encephalitis/meningitis? Y N 7 Any history of seizures/convulsions/epilepsy? Y N

Any history of being knocked out? Y N Any history of passing out spells, or other loss of consciousness? Y N Any allergies? (List what you are allergic to, and what it does to you.) Medicines:__________________________________________________________ ___________________________________________________________________ Foods:______________________________________________________________ ___________________________________________________________________ Environmental:_______________________________________________________ ___________________________________________________________________ Please list all other surgeries: WHAT WHERE WHEN _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ Please list all other hospitalizations: WHY WHERE WHEN _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ _____________________________ ______________________________ _____________________ List all other medical conditions, health problems, and diagnoses you have:_____ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List any medicines, other prescriptions, over-the-counter preparations, food supplements, or vitamins you are taking: ______________________________ ______________________________ _____________________ ______________________________ ______________________________ _____________________ ______________________________ ______________________________ _____________________ ______________________________ ______________________________ _____________________ Has any change in your diet been recommended to you? Y N 8 Date of last physical exam?_____________________________________________ Findings of last physical exam?__________________________________________ ___________________________________________________________________

Any blood or other labs test in last two years, and results?_____________________ ___________________________________________________________________ ___________________________________________________________________ Any other major physical tests ever (for example, EEG, brain scan, radiology tests for stomach, etc.) and results:__________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Any alcohol use? Y N If yes, describe what and how often:______________________________________ ___________________________________________________________________ Tobacco use? Y N If yes, describe what, how often, and how many years:________________________ ___________________________________________________________________ Street drug use/history? Y N If yes, describe what, when and how often__________________________________ ____________________________________________________________________ How much of the following caffeine sources do you have each day: Coffee?_______________________________________ Soft drinks?___________________________________ Tea?_________________________________________ Chocolate?____________________________________ Other?_______________________________________ Please fill in your weight from: 1 yr ago_______________ 2 years ago_____________ 5 years ago_____________ 10 years ago____________ 20 years ago____________ Reason(s) for weight changes?_____________________________________________ _____________________________________________________________________ _____________________________________________________________________ Circle any of the following that you have or have had recently: 9 Skin rash Problems with breathing Heartburn Frequent headaches Nausea/Vomiting Diarrhea Dizziness/lightheadedness Constipation Ulcers Eye/vision problems Any urinary problem Any sexual function problem

Ear/hearing problems Aching / stiff muscles or joints Numbness/Tingling Sinus congestion Hay Fever Goiter / Other thyroid problem Persistent cough Asthma Diabetes Bronchitis Emphysema Cough up phlegm or mucus Hoarseness Frequent colds Arthritis Ringing in ears Dentures Chest pain High Blood Pressure Abdominal/Stomach pain Contact lenses Severe eye pain Hearing aid Swollen ankles Bothered by cold weather Anemia Mouth / lip sores Crying spells Loss of interest Guilty thoughts / feelings Low energy Poor concentration / memory Poor appetite Feel slowed down Feel hopeless / helpless Poor sex drive Hyperactivity Startle easily Excess worry Repeating thoughts Tension Feel on edge Excessive cleaning / counting / checking History of nervous breakdown Temper problems Circle any of the following which apply to you, AND explain below: Exposure to chemicals Mine worker Farmer Metal worker Unusual pets Travel to other countries Welder Histoplasmosis Exposure to tuberculosis Pneumothorax (air leak from lungs) Broken ribs Parasites Hepatitis / Other liver problems Neurological problem Heart Attack Irregular heart beat Heart murmur Blood clots Infection Gall Bladder problems Stroke Kidney stone Blood in urine Menstrual problem High cholesterol Hiatal hernia Broken bones Bedwetting in teen years Genital problem Unusual / dangerous hobbies Radiation exposure History of blood transfusion Told to NOT donate blood Any other serious injury Any history of tumor or cancer Major stress Explain any of the above group:_________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Any other symptoms not listed above?____________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ If married, is your marriage happy and satisfying to you? Y N 10 Are you content with your current occupational status? Y N What would you like to be different about your life at this time?_________________ ___________________________________________________________________ ___________________________________________________________________

Do you feel you are depressed? Y N If yes, when did it start?_________________________________________________ Do you have a history of depression? Y N Do you have a history of any other trouble with stress or “nerves?” Y N Have you seen a psychiatrist, psychologist or counselor ever before? Y N If yes, who, when, where and why?________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Have you ever been hospitalized for nerves, stress, depression or other emotional difficulty? Y N If yes, when, where, and why?____________________________________________ ____________________________________________________________________ Are you taking any medicines for nerves, stress or depression at this time? Y N Have you previously taken any medicines for nerves, stress, or depression? Y N Is there a family history of nerves, depression, other emotional difficulty? Y N Have you ever felt distressed enough to consider or attempt suicide? Y N Is there any family history of attempted or actual suicide? Y N Have you had any previous evaluations for any sleep problem? Y N If yes, where and when?________________________________________________ ___________________________________________________________________ Have you had any previous treatment, including sleeping pills, for any sleep problem? Y N If yes, what, where, and when?___________________________________________ ____________________________________________________________________ ____________________________________________________________________ Is there any family history of any sleeping problem or treatment? Y N 11 If yes, describe:_______________________________________________________ ____________________________________________________________________ If you have grandparents, parents, aunts, uncles, siblings, cousins, or children who have died, please list them and the cause of death for each:___________________________ _____________________________________________________________________ _____________________________________________________________________