About this template
This REM Sleep Behavior Disorder (RBD) screening questionnaire template is designed for healthcare providers, sleep specialists, and clinical researchers to efficiently gather patient symptoms related to dream enactment behaviors during the REM sleep cycle. The form helps identify early indicators of parasomnias and related neurological sleep disturbances.
Built to streamline patient intake, this template allows individuals to document their sleep habits, physical movements during dreams, and medical history in a private, accessible format. Clinicians can review responses prior to consultations to better prepare for clinical evaluations and sleep studies, ensuring a more thorough diagnostic process.
Key features
- Collect detailed sleep behavior histories prior to patient consultations.
- Standardized screening questions for efficient clinical evaluation.
- Fully customizable layout to match clinic or research branding.
- Optimized for desktop, tablet, and mobile completion.
- Instant response collection via Google Drive and Google Sheets.
Use cases
- Initial intake for sleep medicine clinics and sleep study centers.
- Neurological evaluations checking for neurodegenerative precursor signs.
- Clinical research studies tracking sleep disorder demographics.
- Telehealth pre-consultation assessments for remote patients.
What this form collects
- Patient Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Enter your date of birth.
- Do you have vivid or unpleasant dreams? (Multiple choice)Select the option that best describes your typical dream experiences.
- Do your dreams frequently involve being chased or defending yourself? (Multiple choice)Indicate if your dreams involve active physical defense or confrontation.
- Have you ever acted out your dreams while sleeping? (Multiple choice)Examples include punching, flailing arms, kicking, shouting, or jumping out of bed.
- Have these nighttime behaviors resulted in injury to yourself or your bed partner? (Multiple choice)Select yes if bruises, cuts, or other physical injuries have occurred.
- Do other people observe you moving or speaking during sleep? (Multiple choice)Family members or bed partners often notice vocalizations or sudden movements.
- Do you wake up abruptly with a clear recollection of your dream action? (Multiple choice)Recall whether you immediately remember the dream content upon waking from a physical movement.
- Describe any specific sleep behaviors or recent incidents (Paragraph)Provide additional details regarding any violent movements, dream contents, or concerns.
FAQ
How do I share this template with my patients?
Once you copy the template to your Google Drive, you can share it via a direct link, email, or embed it securely on your practice's patient portal.
Can I add custom screening questions specific to my clinic?
Yes, you have full control over the Google Form and can easily add, remove, or modify questions using the standard form editor.
Where are the patient responses saved?
All submissions are automatically stored in a connected Google Sheets spreadsheet linked to your form for easy organization and review.
Is this template free to use?
Yes, this template is entirely free to copy, edit, and distribute using your Google account.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.