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Accredited Polysomnography Programs Form
Disorder
Seizures
Hypersomnia
Other (specify)
Sleep History/Symptoms (Check appropriate boxes)
Excessive daytime sleepiness
Witnessed apneas
Difficulty initiating sleep
Morning headaches
Nocturnal teeth grinding
Snoring
Insomnia
Sleepwalking
Acting out dreams
Muscle/joint aches
Depression
Cataplexy/Narcolepsy
Sleep paralysis
Leg movements
Wakes up choking
Frequent nightmares
S/p surgery for OSA/T&A
Stroke
Thyroid disease
Claustrophobic
Latex allergies
Hiatal hernia
Anxiety...
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