Mercy Sleep Intake Tool
Sleep History
Epworth Sleepiness Score (0-24)
Primary Sleep Complaint
Previous Sleep Disorder Diagnosis
Previous PAP Use
No
Yes, but not currently
Yes, currently
Current Supplemental O2
No
Yes, 24 hr/day
Yes, night only
Inspire Evaluation
No
Yes
Pertinent Medical History
Cardiovascular & Metabolic
High blood pressure
Heart attack
Coronary artery disease (CAD)
Heart failure (CHF)
AFib
Arrhythmia (non-AFib)
Heart disease (other)
Pacemaker
Stroke or TIA
Diabetes
Thyroid disease
Kidney disease/failure
PCOS
Neurological & Psychiatric
Seizure disorder
Parkinson's disease
Cerebral palsy
ALS / motor neuron disease
Multiple sclerosis
Head injury / concussion
Memory loss / dementia
Depression
Anxiety disorder
PTSD
Bipolar or mood disorder
ADHD
History of vehicle accident
Pulmonary, Pain & Other
Asthma
COPD / emphysema
Chronic bronchitis
Pulmonary hypertension
Pulmonary fibrosis
Bronchiectasis
Lung cancer
Hypoventilation syndrome
Cystic fibrosis
Myasthenia gravis
Restrictive lung disease
Nighttime heartburn / GERD
Chronic pain condition
Allergies or sinus problems
Surgical History
Tonsillectomy
Adenoidectomy
UPPP
Uvula removal
Deviated septum
Nasal surgery
Jaw reconstruction
Tracheotomy
Inspire implant
Symptoms
Sleep Apnea
Told I snore:
Occasionally
Most nights
Every night
Quiet
Loud
Very loud (heard outside room)
Told I stop breathing during sleep:
Rarely
Weekly
Nightly
One episode
Multiple episodes per night
Awaken choking or gasping:
Rarely
Weekly
Several nights/week
Awaken with headaches:
Rarely
1-2 mornings/week
Most mornings
Tired or sleepy during the day:
Mild (annoying)
Moderate (affects concentration)
Severe (affects work/driving)
Take naps during the day:
Never
Intentional
Unintentional
Can doze in boring environments:
Rarely
Sometimes
Frequently
Sleep Behavior
Walk in sleep
Talk in sleep
Have wet the bed as an adult
Vivid dream-like scenes as falling asleep
Feel like I walk in a daze
Sometimes unable to tell dreams from reality
Restless Legs
Uncomfortable urges to move legs
These urges improve with activity
These urges get worse in evening or nighttime
Insomnia
Trouble getting to sleep
Trouble staying asleep
Wake up before desired time
Worry about being able to sleep
Wake with fear or anxiety
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