Sleep Study Pre-Screening Questionnaire

Sleep Study Pre-Screening Questionnaire — Form Fields

This healthcare template includes 15 fields. Pre-screening questionnaire for patients being evaluated for sleep disorders. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Phone Number (text, required)
• Referring Physician (text, required)
• Primary Sleep Complaint (dropdown selection, required) — options: Excessive Snoring, Witnessed Apneas, Daytime Sleepiness, Insomnia, Restless Legs, Sleepwalking, Narcolepsy Symptoms, Teeth Grinding
• Average Hours of Sleep Per Night (number, required)
• Sleep Quality (dropdown selection, required) — options: Very Poor, Poor, Fair, Good, Excellent
• Time to Fall Asleep (dropdown selection, required) — options: Under 10 minutes, 10-20 minutes, 20-30 minutes, 30-60 minutes, Over 1 hour
• Symptoms (checkboxes, optional) — options: Morning Headaches, Dry Mouth on Waking, Night Sweats, Frequent Urination at Night, Memory Problems, Irritability, Difficulty Concentrating
• BMI (if known) (number, optional)
• Do You Snore (multiple choice, required) — options: Yes - Nightly, Yes - Sometimes, No, Unknown
• Neck Circumference (dropdown selection, optional) — options: Under 15 inches, 15-17 inches, Over 17 inches, Unknown
• Current Sleep Medications (text, optional)
• Additional Sleep History (long text, optional)