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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

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Sleep History Questionnaire

Sleep Disorders Affect 40 Million Americans

      About 40 million Americans suffer from primary sleep disorders. Most are unaware that typical sleep disorders include: narcolepsy, sleep apnea (obstructive and central), restless leg syndrome), insomnia, and para-somnia.
     Evidence suggests that sleep disorders play a role in virtually all immune, auto-immune, gastro-intestinal and hormonal disorders. In many cases, sleep disorder is the virtual cause of these disorders. This means that the following symptoms may be caused or being perpetuated by your lack of sufficient sleep: gas, ulcers, constipation, diarrhea, frequent colds/flu, male and female complaints, and auto-immune diseases, such as Fibromyalgia, Lupus, MS, Chronic Fatigue, and others.
     Complete the Sleep History Questionnaire to evaluate your sleep patterns by answering all questions accurately.


(DO NOT GUESS- Have a someone observe your sleep, then answer accurately.)

Date:
Name:
E-Mail:

WSN Acct. No.:


Colon / Bowels:

1. What time do you regularly go to sleep and wake up?

2. Number of nights per week you follow this regular sleep and waking schedule?

3. When You sleep, do you:
  a. Have a light on in the room or can see a light in another room from your bed.
  b. Hear noises in the house, traffic, airplanes, etc.
  c. Have animals that wake you in the night or before you are ready to wake.
  d. Hear my partner snoring.
  e. Stay awake or wake up because of partner's snoring.

4. How Long Does It Take You to Go to Sleep? (Ask someone to time you)
  a. 0 - 5 minutes
  b. 5 - 15 minutes
  c. 15 - 30 minutes
  d. 30 - 60 minutes
  e. 60 + minutes

5. How Long Do You Stay Asleep?
  a. Minutes
  b. Sleep for 1-2 hours, wake up, but then returns to bed. (For ex: to urinate)
  c. Awake nightly at 3 a.m.
  d. 7 ½ or 8 hours

6. How Long Could You Sleep If Left Undisturbed?
  a. 9+ hours
  b. Other:

7. When Do You Feel Hungry After You Awaken?
  a. In 30 minutes
  b. In 35 minutes to 2 hours after waking
  c. Longer than 2 hours after waking

8. Do you dream when you sleep?
  a. No
  b. Don't remember my dreams
  c. Yes (If yes, answer D-F)
  d. Short Dreams
  e. Long, Vivid Dreams
  f. Nightmares

9. Snoring:
  a. Do not snore
  b. Snore
  c. Snore heavily, followed by gasping for air

10. Narcolepsy:
  a. Have excessive daytime sleepiness
  b. Unable to remain awake, even after a normal night's sleep
  c. Sometimes catch myself falling asleep while driving during the day.

11. Periodic Limb movement:
  a. Feel dozen to hundreds of limb movement episodes when awake.
  b. Awaken from my sleep by dozen to hundreds of limb movement episodes.
  c. Wake in the morning my arms and legs are aching upon rising.

12. Suffer with Apnea (obstructive breathing without snoring).
  Yes
No

After answering the above questions and indicating your Sleep Test Score below, send this form to WSN by clicking on SEND NOW.

My Sleep History Score is:
    Score - 1      Score - 2      Score - 3

Sleep History Questionnaire Key


Score - 1
Congratulations - Normal Sleep Patterns are indicated if your answers to:
1. Is equal to 7 ½ or 8 hours of sleep
2. 6-7 nights a week
3. No to a. through e.
4. b. 5- 15 minutes
5. d. 7 ½ to 8 hours
6. Not applicable in Normal Sleep Patterns
7. a. In 30 minutes
8. c. Yes and d. Short Dreams
9. a. Do not snore
10. Not applicable in Normal Sleep Patterns
11. Not applicable in Normal Sleep Patterns
12. No Apnea

Score - 2
Minor Sleep Disturbances or Patterns indicated if your answers are the same as the above Normal Sleep Patterns, except you answered #4a. 0-5 minutes, instead of 4b. 5-15 minutes.

Score - 3
Abnormal Sleep Patterns or Sleep Disorder is indicated, if your answers are anything other than those indicated in the Normal or Minor Sleep Patterns.

Score Definition

Score #
1. Congratulations - You have Normal Sleep Patterns! Keep doing what you are doing.

2. Minor Sleep Disturbance or Patterns Indicated - Additional information is required to create a positive and restful sleep environment with some minor adjustments in your current sleep patterns. If not corrected, sleep disorder will eventually occur. Information to correct minor sleep disturbance or patterns can be obtained by ordering the Personal Education Program (PEP) Session #19 on Sleep. Click here to order.

3. Abnormal Sleep Patterns or Sleep Disorder Indicated - A clinical nutrition support program is required to produce natural growth hormones and balance body chemistry to restore natural sleep. Getting more regular sleep helps, but will not correct biochemistry that has been adversely affected by abnormal sleep patterns.

Copyright, 1999 Donna F. Smith