About this template
The Sleep Study Questionnaire is a comprehensive intake form designed for sleep clinics, physicians, and medical specialists to gather vital clinical data prior to a patient's sleep study. This template streamlines the collection of crucial patient background information, including weekday and weekend sleep schedules, sleep latency, frequent awakenings, snoring intensity, breathing pauses, and related symptoms like restless legs or morning headaches.
Beyond basic sleep habits, the questionnaire captures essential lifestyle factors, medical and psychiatric history, current medications, and standardized screening metrics such as the Epworth Sleepiness Scale. By digitizing this pre-evaluation process using Doc2Form, medical practices eliminate cumbersome paper forms, reduce manual data entry errors, and ensure patients can complete their history securely from any device before arriving for their consultation or diagnostic study. This enables clinical staff to review patient profiles in advance and focus immediately on personalized diagnostic care and treatment planning.
Key features
- Collect detailed sleep schedules and wake habits in minutes.
- Screen for sleep apnea symptoms, snoring, and restless legs.
- Gather complete medical, surgical, and medication history.
- Includes standardized daytime sleepiness and insomnia rating scales.
- Mobile-friendly format allows patients to complete forms from home.
Use cases
- Pre-consultation intake for new sleep clinic patients.
- Diagnostic preparation for overnight polysomnography studies.
- Clinical research tracking sleep disorders and lifestyle correlations.
- Telehealth preliminary assessments for chronic fatigue or insomnia.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Enter your date of birth.
- Who is completing this form? (Multiple choice)Indicate whether the patient or a caregiver is filling out this questionnaire.
- Reason for Appointment Request (Paragraph)Briefly describe your main sleep concerns or symptoms.
- Sleep Schedule: Weekdays (Short answer)What time do you typically go to bed and wake up on weekdays?
- Sleep Schedule: Weekends (Short answer)What time do you typically go to bed and wake up on weekends?
- Sleep Onset Latency (Short answer)On average, how many minutes does it take you to fall asleep after turning off the lights?
- Do you frequently wake up during the night? (Multiple choice)Select your frequency of nighttime awakenings.
- Snoring Status (Multiple choice)Has anyone observed that you snore loudly?
- Snoring Loudness Rating (Linear scale)If you snore, how loud is it compared to normal conversation?
- Breathing Pauses or Gasping (Multiple choice)Has anyone noticed you stop breathing, choke, or gasp during sleep?
- Morning Headaches (Multiple choice)How often do you wake up with headaches?
- Restless Legs Symptoms (Multiple choice)Do you experience unpleasant creeping or crawling sensations in your legs when resting?
- Daily Caffeine Servings (Short answer)How many caffeinated beverages (coffee, tea, soda, energy drinks) do you consume daily?
- Weekly Alcoholic Beverages (Short answer)How many alcoholic drinks do you consume in an average week?
- Tobacco Use Status (Multiple choice)Do you currently use tobacco products?
- Height and Weight (Short answer)Enter your height and current weight in pounds.
- Neck Circumference (Short answer)If known, enter your approximate neck circumference in inches.
- Current Medications and Dosages (Paragraph)List all prescription medications, over-the-counter drugs, and supplements you currently take.
- Medication List Upload (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the document you wish to attach.
- Allergies and Adverse Reactions (Paragraph)List any known drug, food, or environmental allergies.
- Additional Notes for Your Doctor (Paragraph)Share any other symptoms or details you would like your physician to review.
FAQ
What is the primary purpose of this sleep study questionnaire?
This questionnaire collects comprehensive information regarding a patient's sleep patterns, medical history, and symptoms. Clinicians use this data to evaluate potential sleep disorders and plan diagnostic tests.
Can I customize the questions to fit my clinic's specific intake protocol?
Yes. Once you convert this template into Google Forms via Doc2Form, you can easily add, remove, or modify any questions to align with your practice's exact requirements.
How do patients access and complete the form?
You can share the form via a direct link, email it to patients ahead of their appointment, or embed it securely on your healthcare provider website.
Can patients upload their current medication lists or documents?
Yes. The form includes designated fields where patients can list medications or paste links to supporting health documents.
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.