Alliance Sleep Questionnaire (ASQ) Summary Report

The information below is a summary of the patient’s self‐reported responses

It HAS NOT BEEN CONFIRMED BY A CLINICIAN AND IS NOT intended to provide a diagnosis
This report may not reflect unanswered question, n/a = not answered
Patient Summary:
Name: Test, Full DOB: 1910‐01‐01 / Gender: F MRN: n/a
Age: 90 yrs
Date ASQ Completed: 2014‐06‐10 Ethnicity: Hispanic Race: Black or African BMI: 23.6
or Latino American

Sleep History:
Reported Sleep Complaint(s): Previous sleep diagnosis: Current treatment(s) for sleep issues:
Snoring Sleep Apnea (breathing stops at night) Medication
My breathing stops at night Insomnia CPAP/BiPAP type machine
Sleepiness during the day Circadian Rhythm Disturbance Supplemental oxygen
Unrefreshing sleep (Advanced/Delayed Sleep Phase, Prior sleep apnea surgery
Difficulty falling asleep Shift work) Oral appliance or dental device
Difficulty staying asleep REM Behavior Disorder (act out dreams Weight loss
Difficulty keeping a normal sleep in my sleep) Sleep position modification
schedule Sleepwalking Provent nasal device
Talk, walk and/or other behavior Other Herbal product/nutritional supplement
in my sleep Cognitive Behavioral Therapy (CBT)
Nightmares or abnormal dreaming Sleep hygiene/other behavioral
Act out dreams in my sleep modification
Restless or unpleasant sensations Other
in my legs
Weakness in muscles of the face,
neck, arms or legs when you laugh
or are surprised
Other

Been to a sleep specialist: Yes Type of PAP: Reported nights use per week: 5 nights
CPAP per week
Reported hours use per night: 5 hours
per night

Focused Upper Airway History: Type of Nose, Jaw or Sleep Apnea Surgery:
Orthodontics/braces/headgear Nasal surgery
Wisdom teeth removed Radiofrequency Ablation (RFA) of the turbinates or
Tonsils and/or adenoids removed turbinectomy
Nose or jaw fractures Uvulopalatopharyngoplasty (UPPP) or Laser Assisted
Other Uvulopalatoplasty (LAUP)
Maxillomandibular osteotomy or Advancement (MMO
or MMA) or surgery on one or both jaws
Genio Tubercle or Glossus Advancement (GGA) or Hyoid
Suspension
Other
Don't know
Current Medications: Test, Full, MRN n/a
test1 ‐ Daily
test2 ‐ As needed
test3 ‐ Daily

NOSE: Test, Full, MRN n/a

NOSE Score: 20 NOSE3: Trouble nose Severe Problem
breathing
NOSE1: Nasal congestion or Severe Problem NOSE4: Trouble Severe Problem
stuffiness Sleeping
NOSE2: Nasal blockage or Severe Problem NOSE5: Unable to get Severe Problem
obstruction air during exercise

Family History: Test, Full, MRN n/a

Insomnia: mother, father, sibling, child RLS: mother, father, sibling, child

Sleep apnea: mother, father, sibling, child Sleepwalking: mother, father, sibling, child

Narcolepsy: mother, father, sibling, child Other: One of the enduring mysteries of
alcohol research is that when you
tally up all the booze that people
report consuming when the:
mother, father, sibling, child

Social History: Test, Full, MRN n/a

Bed partner: Partner in same bed Alcohol: 5 drinks per week
Exercise: n/a Caffeine: 5 drinks per day
Tobacco: Former cigarette smoker Current Last caffeine: n/a
smokeless or other tobacco user

Schedule: Test, Full, MRN n/a

Occupation: scientist Work/School Employed full‐time (includes
status: volunteer work)
Employed part‐time (includes
volunteer work)
A full‐time student
A part‐time student
Full‐time caretaker of another person
Full‐time homemaker
Retired
On disability
Type of sched: Irregular Crosses time Yes
zones routinely:
Work hours: 06:00 PM to 01:00 AM School hours: 11:00 AM to 04:00 PM
Primary Sleep Schedule (e.g. Weekday) Secondary Sleep Schedule (e.g. Weekend)
Bedtime 03:00 AM Bedtime 01:00 AM
Sleep latency 5 minutes Sleep latency 5 minutes
Awakenings 5 per night Awakenings 5 per night
Time spent n/a hours and 5 minutes Time spent n/a hours and 5 minutes
awake awake
Rise time 10:00 AM Rise time 12:00 PM
Reported total n/a hours and 5 minutes Reported total 10 hours and n/a minutes
sleep time sleep time
Naps: 5 per month for 5 hours and for 5 Last screen time 3 hours or longer
minutes before bedtime:
rMEQ Score: 18 Sleep disrupted Bed partner
by: The need to care for another (i.e.
children, elderly parent, etc.)
Pet(s)
Pain/discomfort
The need to urinate
Bed/mattress
Light
Worries
Temperature
Noise

Fatigue/Sleepiness Summary: Test, Full, MRN n/a

Epworth (ESS) Score: 0 Fatigue Scale (FSS): 36
ESS1: Sitting and reading Would Never Doze FOSQ Score: 5.56
ESS2: Watching TV Would Never Doze Falls asleep while Always (5‐7 times per week)
driving:
ESS3: Sitting inactive in a Would Never Doze Accidents/near misses 5, most recent in 2010
public place caused by sleepiness:
ESS4: Passenger in car Would Never Doze Falls asleep at work: Always (5‐7 times per week)
for an hour
ESS5: Lying down in Would Never Doze Difficulty staying 5 times per week
afternoon awake during the day:
ESS6: Sitting & talking to Would Never Doze Excessive sleepiness: Always (5‐7 times per week)
someone
ESS7: Sitting quietly Would Never Doze Sleep attacks: 5 times per week
after lunch w/o alcohol
ESS8: In a car, stopped Would Never Doze Automatic behaviors: 5 times per week
for a few min in traffic

Sleep Disordered Breathing Symptoms: Test, Full, MRN n/a

Loud Snoring: Always (5‐7 times per week) Breathing Always (5‐7 times per week)
Snorting or Gasping: Always (5‐7 times per week) stops/choke/
struggle for breath:
Morning Headaches: Always (5‐7 times per week) Frequent wakenings: Always (5‐7 times per week)

PAP Use: Test, Full, MRN n/a

CPAP USE: Mask / Equipment Details:
Falls asleep without mask: Occasionally Mask type / name: Full face mask /Mirage
Removes mask in sleep: Occasionally Mask size: Other
Forgets to put mask back on Occasionally Mask last replaced: In the last 3‐6 months
after trip to bathroom
Forgets to use PAP with I rarely nap Opinion of current Do not like my mask
nap: mask:
Leaves PAP at home when I rarely travel Tube last replaced: In the last 3‐6 months
traveling:
Uses Chinstrap Occasionally Filters last replaced: In the last 3‐6 months
 Humidification: Problems with PAP: Improvements with PAP:
Experiences nasal Occasionally Frequently wakes me Less choking/gasping in my
congestion with PAP: up sleep
Has dry mouth / sore throat Occasionally Occasional mask air Snore less or not at all
in morning: leakage Sleep quality is better
Uses heated humidifier? Don't know, . Noisy Nasal congestion/ allergies are
Set at Frequently have to better
Uses heated tube? adjust and fuss with Not napping or dozing off as
Frequency of water in tube: Don't know the mask often
Pressure on nasal Memory, concentration and
bridge or nostrils focus are better
Trouble with the air Wake up less often during the
pressure (too high or night
low) Fewer headaches when I wake
Water condensation in up
the mask Have more energy
Skin irritation Blood pressure is better
Causes gas or bloating Do not toss
Uncomfortable GERD (reflux/ heartburn) is
I wish I could wear better
glasses with it More alert during the day
Eye irritation Feel more refreshed when I
My bed partner wake up
complains about it Go to the bathroom less often
Difficult for me to put at night
on and take off Less sleepy during the day
I need a different size Mood is better
Nose bleeds Other
Other

Insomnia Symptoms: Test, Full, MRN n/a

Insomnia Scale (ISI): 28 Meets ISQ diagnostic No
criteria:
Difficulty falling asleep: Very severe Problems waking too Very severe
early:
Difficulty staying asleep: Very severe Frequent wakenings: Always (5‐7 times per week)
Satisfaction with current Very dissatisfied Extent prob interferes Very much interfering
sleep pattern: with daily functioning:

Restless Legs Symptoms: Test, Full, MRN n/a

Current Probability: Unlikely Current Severity Level: Not applicable

Limb discomfort/ Yes, it is still a problem for Frequency of n/a

unpleasant sensation while me now symptoms:
sitting/ lying down:
Urge to move with relief Yes, it is still a problem for Level of distress: n/a
upon movement: me now
Unpleasant sensations Don't know Age of onset: 5
assoc with muscle cramps:
Began with pregnancy: n/a Ended with same n/a
pregnancy:
Narcolepsy/Cataplexy Symptoms: Test, Full, MRN n/a
Muscle weakness or buckling knees when... Feeling of paralysis Always (5‐7 times per week)
Tell or hear a joke: Less than once/month when falling asleep or Age of onset: 5 years old
awakening:
Laugh: Less than once/month Dreamlike state when Always (5‐7 times per week)
falling asleep: Age of onset: 5 years old
Age of onset: 5 years olds

Nighttime Behaviors: Test, Full, MRN n/a

Legs twitch/kick in sleep: 5 times per week Scream, act out dreams 5 times per week Age of
or act confused: onset: 5
Walk in sleep: 5 times per week Age of Violent or injurious 5 times per week Age of
onset: 5 behavior: onset: 5
Eat in sleep: 5 times per week Nightmares: 5 times per week
Grind teeth: Sometimes Seizures, convulsions Yes
or “fits” during sleep:

Psychiatric Scales: Test, Full, MRN n/a

Depression Scale (PHQ‐9): 18 PHQ1. Little interest or More than half the days
pleasure in doing things
Anxiety Scale (GAD‐7): 14 PHQ2. Feeling down, More than half the days
depressed, or hopeless
GAD1. Feeling nervous, More than half the days PHQ3. Trouble falling More than half the days
anxious, or on edge or staying asleep,
sleeping too much
GAD2. Not being able to More than half the days PHQ4. Feeling tired or More than half the days
stop or control worrying having little energy
GAD3. Worrying too much More than half the days PHQ5. Poor appetite More than half the days
about different things or overeating
GAD4. Trouble relaxing More than half the days PHQ6. Feeling bad More than half the days
about yourself
GAD5. Being so restless that More than half the days PHQ7. Trouble More than half the days
it is hard to sit still concentrating
GAD6. Becoming easily More than half the days PHQ8. Moving or More than half the days
annoyed or irritable speaking slowly or
very fidgety or restless
GAD7. Feeling afraid as if More than half the days PHQ9. Thoughts that More than half the days
something awful might you would be better off
happen dead or of hurting
yourself in some way
 Scoring:
Abbreviation Form Name Scoring/Interpretation
ESS Epworth Sleepiness Scale Range is 0‐24, ≥ 10=sleepy; ≥ 18=very sleepy
FSS Fatigue Severity Scale Range is 7‐63, ≥36 indicates fatigue
FOSQ Functional Outcomes of Sleep Range is 5‐20; higher scores are better
Questionnaire
GAD‐7 Generalized Anxiety Disorder 0‐4 = minimal, 5‐9 = mild, 10‐14 = moderate, 15‐21 = severe
ISI Insomnia Severity Index 0‐7=not clinically significant; 8‐14=subthreshold insomnia;
15‐21=moderate insomnia; 22‐28=severe insomnia
ISQ Insomnia Symptom Yes, No, Unavailable
Questionnaire
PHQ‐9 Patient Health Questionnaire 1‐4 = minimal, 5‐9 = mild, 10‐14 = moderate,
(Depression) 15‐19 = moderately severe, 20‐27 = severe
RLS Current Probability ASQ RLS Scoring Algorithm Unlikely, Unlikely [Possibly in Past], Possible, Likely
RLS Current Severity ASQ RLS Scoring Algorithm Range is 0‐12; higher scores indicate increased severity
rMEQ Morningness‐Eveningness 4‐7=definitely evening; 8‐11=Moderately Evening;
Questionnaire‐reduced 12‐17=Neither; 8‐21=Moderately Morning;
22‐25=Definitely Morning