Mercy Sleep Intake Tool

Sleep History

What is your primary sleep complaint?
Have you used CPAP at home?	No Yes, but not currently Yes, currently
Is this study being done to see if you qualify for the Inspire® device?	No Yes
Do you currently use supplemental oxygen at home?	No Yes, 24 hr/day Yes, night only

Medications

List medications taken today that help with sleep, wakefulness, pain, anxiety/depression, or other relevant conditions.

Pertinent Medical History Please check all conditions that have been diagnosed by a physician

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 Other:

Symptoms Please check all that apply based on your own experience or what others have told you

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 Yes, intentionally Yes, unintentionally

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 when 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

Report Narrative

No intake data entered.