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**HBE Preventive Health -- Sleep Assessment Form**

# Please bring your completed assessment form to your appointment.

# To schedule an appointment please call 505 844-HBES (4237).

  ---------------- ------------ ---------- ------------- ---------- -------------------
  **Name:      **                          **Employee               **Date:      **
                                           ID#:      **             

  **Male**         **Age:       **Phone:                 **Email:   
  **Female**            **           **                       **    
  ---------------- ------------ ---------- ------------- ---------- -------------------

> **Sleep and Health History**
>
> In general, would you describe your sleep as: Refreshing Not
> Refreshing
>
> What is the [quality]{.smallcaps} of your sleep?
>
> Extremely Good
>
> Very Good
>
> Good
>
> Adequate
>
> Fair
>
> Poor
>
> Very Poor
>
> Extremely Poor
>
> On a scale of 0 to 10, how [sleepy]{.smallcaps} are you during the
> day?

#### Not Sleepy 0 1 2 3 4 5 6 7 8 9 10 Extremely Sleepy

> On a scale of 0 to 10, how [tired]{.smallcaps} are you during the day?

#### Not Tired 0 1 2 3 4 5 6 7 8 9 10 Extremely Tired

> On average, how long does it usually take you to fall asleep?      
>
> On average, how many hours in bed do you usually spend in a
> night?     
>
> On average, how many hours of sleep do you usually get in a
> night?     
>
> Do you wake up a lot during your sleep?      
>
> If yes, how many times per night on average?      
>
> If awakened, do you have trouble returning to sleep?      

If awakened, how much time awake do you spend at night trying to get
back to sleep?      

Would you or others say you snore loudly? YES NO Don't Know

> Have you or others moved from the bed because of your snoring? YES NO
> N/A
>
> Would you or others say that you have other trouble breathing while
> you sleep -- do you stop breathing, choke, gasp, or struggle for
> breath? YES NO Don't Know
>
> While lying still in bed, do you have uncomfortable sensations in your
> legs that prevent you from sleeping? YES NO
>
> If yes, do these sensations go away when you move your legs? YES NO
>
> Would you or others say that you twitch or jerk your legs while you
> sleep? YES NO
>
> Have you or others ever moved from your bed because of your
> twitches/leg jerks?
>
> YES NO N/A
>
> Indicate which, if any, symptoms you\'ve been having at least weekly
> during the past month:

+---------------------------------+------------------------------------+
| > Wake up with dry mouth        | > Difficulty with memory           |
+---------------------------------+------------------------------------+
| > Problems controlling your     | > Feeling anxious                  |
| > blood pressure                |                                    |
+---------------------------------+------------------------------------+
| > Morning headaches             | > Feeling depressed                |
+---------------------------------+------------------------------------+
| > Difficulty concentrating      | > Disturbing dreams or nightmares  |
+---------------------------------+------------------------------------+

Indicate which, if any, of the items listed below wake you up or keep
you from sleeping:

+---------------------------------+------------------------------------+
| Restless legs or leg jerks      | > Pain                             |
+---------------------------------+------------------------------------+
| Trouble breathing               | > Racing thoughts/ Can't turn off  |
|                                 | > your mind                        |
+---------------------------------+------------------------------------+
| Indigestion/ Reflux             | > Anxiety or fear about something  |
+---------------------------------+------------------------------------+
| Needing to use the bathroom     | > Needing a drink of water         |
|                                 |                                    |
| Other:                          |                                    |
+---------------------------------+------------------------------------+

  ---------------------------------- ------------------------------------
  Sleep Problem (indicate all that   Duration of problem
  apply)                             

  Insomnia                                Months      Years

  Nightmares                              Months      Years

  Poor Sleep Quality                      Months      Years

  Sleep Breathing Problem                 Months      Years

  Sleep Movement Problem                  Months      Years

  Other:                                  Months      Years
  ---------------------------------- ------------------------------------

# 

Please list any medications, supplements or vitamins, prescribed or over
the counter, you are currently using on a regular basis for any
condition:      

Please list any medications, supplements, vitamins, oxygen, CPAP, nasal
strips, dental devices etc. that you use to improve your sleep:      

On average how many beverages containing caffeine do you consume a day?
     

Count an 8oz. serving as one beverage. For example: a can of soda is
12oz. = 1 ½ beverages.

# When was your last complete physical exam?      

Have you had an overnight sleep study or visited a sleep medicine
doctor? YES NO

Have your tonsils and/ or adenoids been removed? YES NO

Have you had any sinus surgeries? YES NO

Have you had problems with allergies and/ or sinuses? YES NO

Have you had any sinus infections in the past three years? YES NO

Do you have asthma or other lung disease? YES NO

Do you have any chronic disease(s)? YES NO

If yes, please list: **     **

Do you have a family history of any of the following? (Please indicate)

Diabetes Heart disease High blood pressure

Stroke Sleep apnea Restless leg syndrome

Insomnia Depression Other:      

**\
Insomnia Severity Index**

Please answer each of the questions below by indicating the response
that best describes your sleep patterns [in the past week]{.underline}.
Please answer all questions.

+-------------------------+----------+------+--------+------+--------+
| Please rate the current | 0        | 1    | 2      | 3    | 4      |
| (past week's)           |          |      |        |      |        |
| [severity]{.smallcaps}  | None     | Mild | Mo     | Se   | Very   |
| of your insomnia        |          |      | derate | vere | Severe |
| problem(s):             |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
| Difficulty falling      |          |      |        |      |        |
| asleep:                 |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
| Difficulty staying      |          |      |        |      |        |
| asleep:                 |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
| Problem waking up too   |          |      |        |      |        |
| early:                  |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+

+-------------------------+----------+------+--------+------+--------+
| How                     | Very     | A    | Some   | Much | Very   |
| [satisfied/di           |          | Li   |        |      |        |
| ssatisfied]{.smallcaps} | S        | ttle | What   |      | Dissat |
| are you with your       | atisfied |      |        |      | isfied |
| current sleep pattern?  |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
|                         |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
| To what extent do you   | Not at   | A    | Some   | Much | Very   |
| consider your sleep     | all      | Li   |        |      | Much   |
| problem to              |          | ttle | What   |      |        |
| [interfere]{.smallcaps} | Int      |      |        |      | Inter  |
| with your daily         | erfering |      |        |      | fering |
| functioning (e.g.,      |          |      |        |      |        |
| daytime fatigue,        |          |      |        |      |        |
| ability to function at  |          |      |        |      |        |
| work/daily chores,      |          |      |        |      |        |
| concentration, memory,  |          |      |        |      |        |
| mood, etc.)?            |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
|                         |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
| How                     | Not at   | A    | Some   | Much | Very   |
| [                       | all      | Li   |        |      | Much   |
| noticeable]{.smallcaps} |          | ttle | What   |      |        |
| to others do you think  | No       |      |        |      | Noti   |
| your sleeping problem   | ticeable |      |        |      | ceable |
| is in terms of          |          |      |        |      |        |
| impairing the quality   |          |      |        |      |        |
| of your life?           |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
|                         |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+
| How                     | Not at   | A    | Some   | Much | Very   |
| [worried/               | all      | Li   |        |      |        |
| distressed]{.smallcaps} |          | ttle | What   |      | Much   |
| are you about your      |          |      |        |      |        |
| current sleep problem?  |          |      |        |      |        |
+-------------------------+----------+------+--------+------+--------+

Total: \_\_\_\_\_

## 

##   {#section-2 .unnumbered}

## 

## Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following
situations, in contrast to feeling just tired? This refers to your usual
way of life in recent times. Even if you have not done some of these
things recently, try to work out how they would have affected you. Use
the following scale to circle the most appropriate number for each
situation:

+--------------------+-----------+-----------+-----------+-----------+
| **Situation:**     | **Chance  |           |           |           |
|                    | of        |           |           |           |
|                    | dozing:** |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
|                    | 0         | 1         | 2         | 3         |
|                    |           |           |           |           |
|                    | would     | slight    | moderate  | high      |
|                    | never     | chance of | chance of | chance of |
|                    | dose      | dozing    | dozing    | dozing    |
+--------------------+-----------+-----------+-----------+-----------+
| Sitting & Reading  |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| Watching TV        |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| Sitting inactive   |           |           |           |           |
| in a public place  |           |           |           |           |
| (e.g. a theater or |           |           |           |           |
| movie)             |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| As a passenger in  |           |           |           |           |
| a car for an hour  |           |           |           |           |
| without a break    |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| Lying down to rest |           |           |           |           |
| in the afternoon   |           |           |           |           |
| when circumstances |           |           |           |           |
| permit             |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| Sitting & talking  |           |           |           |           |
| with someone       |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| Sitting quietly    |           |           |           |           |
| after lunch        |           |           |           |           |
| without alcohol    |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+
| In a car, while    |           |           |           |           |
| stopped for a few  |           |           |           |           |
| minutes in traffic |           |           |           |           |
+--------------------+-----------+-----------+-----------+-----------+

Total: \_\_\_\_\_

**Sleep Hygiene**

+-------------------------------------------------+----+----+---------+
| Do you awaken at the same time each day? If no, | Y  | NO |         |
| usual workday wake up time:       usual wake up | ES |    |         |
| time on day off:                                |    |    |         |
+-------------------------------------------------+----+----+---------+
| Do you participate in regular exercise at least | Y  | NO |         |
| 3 days a week?                                  | ES |    |         |
+-------------------------------------------------+----+----+---------+
| If you exercise, do you exercise at least 4     | Y  | NO | Don't   |
| hours prior to going to bed?                    | ES |    | e       |
|                                                 |    |    | xercise |
+-------------------------------------------------+----+----+---------+
| If you nap, do you nap only early in the day    | Y  | NO | Don't   |
| for no more than 20 minutes?                    | ES |    | nap     |
+-------------------------------------------------+----+----+---------+
| Do you have a comfortable sleep environment?    | Y  | NO |         |
| This means an environment that includes; a      | ES |    |         |
| comfortable bed, comfortable bedroom            |    |    |         |
| temperature, a clean, quiet and darkened        |    |    |         |
| bedroom.                                        |    |    |         |
+-------------------------------------------------+----+----+---------+
| Do you have techniques or rituals to help you   | Y  | NO |         |
| relax at bedtime? Such as: taking a warm bath,  | ES |    |         |
| listening to relaxing music, deep breathing, or |    |    |         |
| imagery.                                        |    |    |         |
+-------------------------------------------------+----+----+---------+
| Do you expose yourself to sunlight each         | Y  | NO |         |
| morning?                                        | ES |    |         |
+-------------------------------------------------+----+----+---------+
| Do you smoke less than 2 hours before going to  | Y  | NO | Don't   |
| bed?                                            | ES |    | smoke   |
+-------------------------------------------------+----+----+---------+
| Do you check the time if you awaken at night?   | Y  | NO | Don't   |
|                                                 | ES |    | wake up |
|                                                 |    |    | @ night |
+-------------------------------------------------+----+----+---------+
| Do you drink more than 2 cups of coffee or      | Y  | NO | Don't   |
| other caffeine containing beverages per day?    | ES |    | drink   |
|                                                 |    |    | c       |
|                                                 |    |    | affeine |
+-------------------------------------------------+----+----+---------+
| Do you drink alcohol within 2 hours of going to | Y  | NO | Don't   |
| bed?                                            | ES |    | drink   |
|                                                 |    |    | alcohol |
+-------------------------------------------------+----+----+---------+
| Do you eat large meals within 3 hours of going  | Y  | NO |         |
| to bed?                                         | ES |    |         |
+-------------------------------------------------+----+----+---------+
| Do you go to bed when you are not "sleepy"? In  | Y  | NO |         |
| other words, do you go to bed based on the      | ES |    |         |
| time, boredom, or because you think you should? |    |    |         |
+-------------------------------------------------+----+----+---------+
| Do you use your bedroom for activities other    | Y  | NO |         |
| than sleep or sex? Such as: watching TV, paying | ES |    |         |
| bills, discussing the problems of the day,      |    |    |         |
| studying or work activities or do you have an   |    |    |         |
| office in your bedroom?                         |    |    |         |
+-------------------------------------------------+----+----+---------+

Please describe your bedtime routine (what do you do in the hour before
you go to bed):      

## 

**Work/ Life Balance**

Do you travel much for work? YES NO

If yes, how often? **     **

How many hours, if any, do you work over your normal work schedule each
week? **     **

Do you take at least a 30 minute break away from your work each day? YES
NO

Do you take time to relax each day? YES NO

What, if any, specific activities or techniques do you use to relax or
manage your stressors?

Please list: **     **

How much time do you spend watching TV/ playing computer games / or
other non work related computer activities? **     ** per day       per
week

Do you have regular opportunities to socialize with friends/ peers/
family? YES NO

Do you have any special interests or hobbies (exclude work related
activities)? YES NO

If yes, are you satisfied with the amount of time you get to pursue
these interests? YES NO

On a scale of 0 to 10, how satisfied are you with your job?

#### 

#### Not Satisfied 0 1 2 3 4 5 6 7 8 9 10 Extremely Satisfied

On a scale of 0 to 10, how well do you feel that you balance your work
and your life?

#### 

#### Not Balanced 0 1 2 3 4 5 6 7 8 9 10 Extremely Balanced

**Employee Health 3331-2**

**505-844-HBES (4237)**

[http//hbe.sandia.gov](http://hbe.sandia.gov/)