15 W. Dry Creek Circle 6169 S. Balsam Way; Suite 290
Littleton, CO 80120-4427 Littleton, Colorado 80123
Phone: (303) 798-1309 Fax: (303) 798-2319
Ear, Nose & Throat Center
Specialists of the Ear, Nose and Throat / Head and Neck Surgery / Facial Plastic Surgery
Evaluation of Dizziness & Vestibular Disorders
For more information see us at our web site ! http://www.ENT Center.Net
Please fill this questionnaire out with your spouses
help prior to your appointment to see Dr. Culberson.
Bring the completed form with you so we can
review it. You might be surprised
by your spouses response !
The form shown below can be downloaded to your computer by double clicking
the MS Word file listed to the left: 
Sleep Apnea Questionnaire
Please read each item carefully and answer all questions. For some questions you will be asked to choose one or more answers. if you are asked to provide specific information in writing, use the blank space following the question. if a certain question does not apply to your case, please indicate so by writing 'N/A'.
I. Personal Data
Name: Last First ___________ M.I.__________
 |
Home Address: Street & #_______________________________________________________________ |
|
City, State & Zip Code________________________________________________________ |
Home Phone: ( ) -___________ Work Phone: ( ) -____________
Main Occupation: _____________________________________________________________________
Additional Occupation:__________________________________________________________________
|
Age:_______ Date of Birth: Month _____ Day _____ Year ____ |
|
Country of Birth:_______________ |
|
Sex: (circle) Male Female |
Race: (circle) Asian Black Caucasian Hispanic Other (specify)
Height: __________ft. _________inches Weight: lbs.
|
Marital Status: (circle) Single Engaged Married Separated Divorced Widowed |
|
Language(s) Routinely Spoken: (list in order from most used to least used) |
Are you a vocal performer? (check one) yes_______ no_______
if yes, are you a (circle) Singer Actor Announcer Clergy Other (specify)
Are you a wind instrument player? (check one) yes_______ no_______
Please continue to the next page
|
Initial Questionnaire-- page 2 |
II. Background information
1. Who referred you to this office? (circle) Self Spouse Mate Parent (s) Child(ren)
Friend(s)___________Physician (specify) _______________ Other(s) (specify) ___________________________
|
2. in your own words, describe precisely the nature and severity of your problem, and why you came here:______________________________________________________________________________________________________________________________________________________________ |
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
|
3. How long have you had this problem? (specify) ____________________________________________ |
4. Did your problem start: (circle) Suddenly Gradually intermittently (off & on)
Other (specify): ____________________________________________________________________
|
5. in your opinion, what caused your problem? (explain):______________________________________
|
|
__________________________________________________________________________________ |
6. Are you primarily concerned with: (circle) Snoring Disturbed Sleep Sleep Apnea
Other (specify): ____________________________________________________________________
|
7. On a scale of 0 to 5, where 0 = no effect, 1 = mildly negative, 3 = moderately negative, and 5 |
= extremely negative, please rate the effects of your problem on your personal life.
no mildly moderately extremely
effect negative _ negative _ negative
0 1 2 3 4 5
|
8. On a scale of 0 to 5, where 0 = no effect, 1 = mildly negative, 3 = moderately negative, and
|
5 = extremely negative, please rate the effect of your problem on your job performance. (Circle).
no mildly moderately extremely
effect negative - negative - negative
0 1 2 3 4 5
|
9. Explain your treatment goals (what you wish to accomplish after having received medical treatment in this facility):________________________________________________________________________
|
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please continue to the next page
|
Initial Questionnaire-- page 3 |
III. Snoring
|
1. On a scale of 0 to 7, where 0 = no problem, 1 = mild problem, 4 = moderate problem, and |
|
7 = severe problem, please rate your overall perception of your snoring problem. |
no mildly moderately extremely
problem problem - problem - problem
0 1 2 3 4 5
|
2. On a scale of 0 to 5, where 0 = no problem, 1 = mild problem, 3 = moderate problem, and 5 = severe problem, please rate other people's perception of your snoring problem. |
no mildly moderately extremely
problem problem - problem - problem
0 1 2 3 4 5
|
3. On a scale of 1 to 5, where 1 = much worse, 3 = no change, and 5 = much better, please rate the condition of your snoring since the onset of the first symptoms. |
much no much
worse - change - improved
1 2 3 4 5
|
4. On a scale of 0 to 5, where 0 = inaudible, 1 = extremely soft, 3 = moderately loud, and S = extremely loud, please rate the loudness level of your snoring. |
inaudible extremely moderately extremely
soft loud loud
0 1 2 3 4 5
5. On a scale of 0 to 5, where 0 = never, 1 = rarely, 3 = occasionally, and 5 = always, please
rate the frequency of your snoring.
never rarely - occasionally - always
0 1 2 3 4 5
|
6. On a scale of 1 to 5, where 1 = significantly worse, 3 = no change, and 5 = significantly improved, please rate your relationship(s) with your 'significant other(s)' since the onset of symptoms. |
significantly no significantly
change - improved
1 2 3 4 5
|
7. On a scale of 0 to 5, where 0 = not bothersome, 1 = mildly bothersome, 3 = moderately bothersome, and 5 = extremely bothersome, please rate the extent to which your snoring bothers (an)other person(s) who share(s) a bed / bedroom with you. |
not mildly moderately extremely
bothersome bothersome bothersome bothersome
0 1 2 3 4 5
Please continue to the next page
|
Initial Questionnaire- page 4 |
|
8. Have you ever: |
|
a. Been “evicted” from your Bed ____ Bedroom ____ Adjacent Part of the House _____ because of your snoring? (check one of appropriate choices above) yes______ no______ . |
|
b. Lost the companionship of a Bed / Bedroom partner because of your snoring? |
(check one): yes ______ no______
9. Have you ever been treated for snoring? (check one) yes______ no______
if no, skip to question 1 2. if yes, when? (month ______ / year _____)
Where? (clinic or institution) __________________________________________________________
By whom? (physician name & specialty): ________________________________________________
How? (describe type and course of treatment): ___________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
|
10. On a scale of 1 to 5, where 1 = much worse, 3 = no change, and 5 = much improved, please rate the condition of your snoring problem following snoring treatment. |
much no much
worse change - improved
1 2 3 4 5
|
11. if on a scale of 1 to 5, where 1 = very dissatisfied, 3 = neutral, and 5 = very satisfied, please rate your satisfaction with the snoring treatment you received thus far. |
very neutral very
dissatisfied satisfied
1 2 3 4 5
|
12. On a scale of O to 5, where 0 = unmotivated, 1 = mildly motivated, 3 = moderately motivated, and 5 = very motivated, please rate the degree of your motivation to alleviate your snoring problem. |
not mildly moderately very
motivated motivated motivated motivated
0 1 2 3 4 5
IV. Steep
1. Have you ever undergone a sleep study? (check one) yes______ no______
if no, skip to question 2. if yes, when? (month or the 1 year): ___________________________
Where? (clinic / institution): _________________________________________________________
By whom? (physician name & specialty): ______________________________________________
Was it a full night polysomnography in a sleep lab? (check one) yes______ no______
if not, explain how you were tested: __________________________________________________
2. Have you ever been diagnosed with sleep apnea? (check one) yes______ no______
if no, skip to the next section.
if yes, is your sleep apnea clearly associated with snoring? (check one) yes______ no______
Please continue to the next page
|
Initial Questionnaire-- page 5 |
3. Have you ever been treated for sleep apnea? (check one) yes______ no______
if no, skip to the next section.
if yes, when? (month & year): ______________________________________
Where? (clinic & institution): ________________________________________________________
|
By whom? (physician name & specialty): _______________________________________________ |
|
How? (describe type and course of treatment): __________________________________________ |
3. Did you comply with the sleep apnea treatment prescribed? (check one) yes______ no______
if not, why? (explain): _______________________________________________________________
|
4. if on a scale of 1 to 5, where 1 = very dissatisfied, 3= neutral, and 5 = very satisfied, please rate your degree of satisfaction with the sleep apnea treatment you received thus far. |
very very
dissatisfied neutral - satisfied
1 2 3 4 5
|
V. General Health |
|
1. Do you have, or have you had any of the following health problems? [in the space to the left of each item, please check the appropriate response (N = No, Y = Yes, P = Past, C = Current) Provide additional information (specify) in the line provided following each item.] |
N___ Y___ (P__ C__) a. Cardiac (heart):_________________________________________________
N___ Y___ (P__ C__) b. Blood Pressure: (high)___ (low) _____
N___ Y___ (P__ C__) c. Stroke: (CVA)___________________________________________________
N___ Y___ (P__ C__) d. Cancer:________________________________________________________
N___ Y___ (P__ C__) e. Pulmonary / Respiratory: __________________________________________
N___ Y___ (P__ C__) f. Diabetes / Hypoglycemia: _________________________________________
N___ Y___ (P__ C__) g. Gastrointestinal:_________________________________________________
N___ Y___ (P__ C__) h. Bleeding:_______________________________________________________
N___ Y___ (P__ C__) i. Neurologic.:
N___ Y___ (P__ C__) l. Thyroid: (hyper)______ (hypo) _____________________________________
N___ Y___ (P__ C__) k. Allergies: ______________________________________________________
N___ Y___ (P__ C__) i. Endocrine / Hormonal:____________________________________________
N___ Y___ (P__ C__) m. Emotional:_____________________________________________________
N___ Y___ (P__ C__) n. Nose / Sinus:___________________________________________________
N___ Y___ (P__ C__) o. Throat / Voice:__________________________________________________
N___ Y___ (P__ C__) p. Hearing / Balance:_______________________________________________
N___ Y___ (P__ C__) q. Language / Articulation / Voice / Resonance:__________________________
N___ Y___ (P__ C__) r. Other:_________________________________________________________
Please continue to the next page
|
Initial Questionnaire-- page 6 |
|
2. Are you currently on any medication (prescription or over the counter)?
|
|
(check one) yes______ no______ if no, skip to question 3. |
|
if yes, please list by name each medicine you are taking, dose per day, the date you began taking it, and the reason(s) for taking the medication. |
a. Medicine: Dose / Day: _______ Beginning Day: _____/ /____
Reason:________________________________________________________________
b. Medicine: Dose / Day: _______ Beginning Day: _____/ /____
Reason:________________________________________________________________
c. Medicine: Dose / Day: _______ Beginning Day: _____/ /____
Reason:________________________________________________________________
d. Medicine: Dose / Day: _______ Beginning Day: _____/ /____
Reason:________________________________________________________________
3. Have you ever had surgery? (check one) yes______ no______
|
if no, Skip to question 4. if yes, please list each surgery, and when and why it was performed.
|
a. Surgery:___________________________________________________ Date: _/ ____/____
Reason:
b. Surgery:___________________________________________________ Date: ____/ ____/____
Reason:
C. Surgery:___________________________________________________ Date: ____/_____/____
Reason:
4. Do you exercise? (check one) yes_____ no_____
if no, skip to question 5. If yes, what type of activity? (specify): ______________________________
How often? (circle) Rarely - Occasionally - 1/2 the time - Frequently - Always - Other (specify):______
5. Do you currently smoke? (check one): yes______ no______ if no, skip to question 6.
If yes, How long have been smoking? (specify)_________ Years: _____________________________________
How many cigarettes per day? (specify): _____________ Cigarettes Brand: _____________________________
|
If you do not smoke now, have you ever smoked in the past? (check one): yes ______ no ______ |
|
If no, skip to question 7. |
|
If yes, How long have you smoked? (specify)________ Years: _____________ |
|
How many cigarettes per day? (specify): _________ Cigarette Brand: _______________________ |
|
When did you quit smoking? (specify) Month:_________ Year:__________ |
7. Are you exposed to cigarette smoke:
a. At home? (check one): yes_____ no_____
b. At work? (check one): yes_____ no_____
8. Do you consume alcoholic beverages (beer / wine / liquor)? (check one) yes_____ no______
If no, skip to question 9. if yes, what type(s)? (specify): _____________________________
If yes, is it usually in the evening or before bedtime? (check one) yes______ no______
How frequently do you have an alcoholic drink? (check appropriate response(s))
_____a. At least one a day _____ b. Four or more a week _____ c. Two or more a week
_____d. Only on weekends _____ e. Only on rare occasions _____ f. Other (explain)____________
Please continue to the next page
|
9. Do you take sleep medication, tranquilizers, or other substances to help you 'relax' or fall asleep |
before bedtime? (check one): yes______ no______
If yes, what type(s)? (specify): ________________________________________________________
|
How often? (circle): Rarely - Occasionally - 1/2 the time - Frequently - Always - Other (specify)____ |
10. Have you recently:
|
a. Gained weight? (check one): yes______ no______ |
|
If yes, over what period of time? (specify): _______ Year(s) & _______Month(s) |
|
How many pounds? (specify)_________ Have you tried to lose it again? yes_______ no______ |
|
b. Lost weight? (check one) yes______ no______ |
|
If yes, over what period of time? (specify): _______ Year(s) & _______Month(s) |
How many pounds? (specify): . Did you try to lose it on purpose? yes______ no______
|
c. Been on a diet to lose weight? (check one): yes______ no______ |
|
11. On a scale of 1 to 5, where 1 = poor, 2 = fair, 3 = average, 4 = good, and 5 = excellent, please rate your current overall health status. |
Poor - average - excellent
1 2 3 4 5
|
12. On a scale of 1 to 5, where 1=extremely low, 2= below (below average), .3= average, 4 = fairly high (above average), and 5 = extremely high, please rate your current energy level. |
Extremely extremely
low - average - high
1 2 3 4 5
Please continue to the next page
Initial Questionnaire-- page 8
|
VI. Miscellaneous |
|
1. On a scale of 0 to 5, where 0 = no problem, 1 = mild problem, 2 = mild to moderate problem, 3 = moderate problem, 4 = moderate to severe problem, and 5 = severe problem, please rate the presence of severity of the following symptoms as they apply to you in the present. (Circle only one number which. best corresponds to your condition.) |
no mild moderate severe
problem problem - problem - problem
a. difficulty falling asleep at night 0 1 2 3 4 5
b. difficulty staying asleep 0 1 2 3 4 5
c. difficulty waking up (feeling tired / unrested in the morning) 0 1 2 3 4 5
d. difficulty staying awake during the day 0 1 2 3 4 5
e. tendency to fall asleep involuntarily during active hours 0 1 2 3 4 5
f. frequent morning headaches 0 1 2 3 4 5
g. frequent napping during the day 0 1 2 3 4 5
ii. difficulty concentrating 0 1 2 3 4 5
i. difficulty remembering things 0 1 2 3 4 5
j. difficulty staying on task (or following through with projects) 0 1 2 3 4 5
k. difficulty in overall daily functioning 0 1 2 3 4 5
i. difficulty staying alert when driving 0 1 2 3 4 5
m. tendency to tire quickly (feel physically weak /easily fatigued) 0 1 2 3 4 5
n. difficulty in moderate physical activity 0 1 2 3 4 5
0. difficulty / reduction in sexual activity 0 1 2 3 4 5
p. difficulty in motor coordination / control 0 1 2 3 4 5
q. tendency to feel frustrated, irritable, impatient & "moody” 0 1 2 3 4 5
r. tendency to become apathetic, withdrawn, uninvolved 0 1 2 3 4 5
s. tendency to feel depressed, "down," or "sad" 0 1 2 3 4 5
t. tendency to feel anxious, restless, nervous, worried 0 1 2 3 4 5
u. tendency to feel unattractive, undesirable, rejected 0 1 2 3 4 5
v.. tendency to respond emotionally, “snap” at people,
argue, or over-react to what they say or do 0 1 2 3 4 5
w. tendency to cry easily or laugh about little (trivial) things 0 1 2 3 4 5
x. difficulty breathing (shortness of breath) during the day 0 1 2 3 4 5
y. difficulty breathing (shortness of breath) at night 0 1 2 3 4 5
z. sensation of choking /gasping for air during sleep 0 1 2 3 4 5
aa. tendency to awaken suddenly with heart pounding 0 1 2 3 4 5
bb. sensation of tightness / fullness in the throat 0 1 2 3 4 5
cc. difficulty breathing through your nose when asleep 0 1 2 3 4 5
dd. sensation of tightness or pressure in the chest 0 1 2 3 4 5
ee. dizzy spells or problems with balance 0 1 2 3 4 5
gg. numbness / weakness of arms / legs / other body parts 0 1 2 3 4 5
|
You have reached the end of the questionnaire. Thank you for your participation. |
