Dr. Kukreja Consultation Form

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Patient Information
1. The Epworth Sleepiness Scale (ESS)
Scoring Key Matrix:
0 Would NEVER doze
1 SLIGHT chance
2 MODERATE chance
3 HIGH chance
Situation 0 1 2 3
1. Sitting and reading
2. Watching TV
3. Sitting, inactive in a public place (e.g., a theatre or a meeting)
4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when circumstances permit
6. Sitting and talking to someone
7. Sitting quietly after a lunch without alcohol
8. In a car, while stopped for a few minutes in traffic

Epworth Score Total: 0 / 24

2. Generalized Anxiety Scale (GAD-7)
Over the last 2 weeks, how often have you been bothered by: Not at all (0) Several days (1) More than half (2) Nearly every day (3)
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Anxiety Total Score: 0 / 21

3. Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by: Not at all (0) Several days (1) More than half (2) Nearly every day (3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Depression Screening Score: 0 / 27

Sleep Disorder Screening Questionnaire

Clinical Screening Metric Question Yes No
1. SNORING
Do you snore?
I have been told that I am a loud snorer.
I snore more loudly when I sleep on my back.
2. OBSTRUCTIVE SLEEP APNEA AND DAYTIME SLEEPINESS
I have been told that I sometimes stop breathing during sleep.
I sometimes wake up short of breath or gasping for air.
I feel that I lack energy; I feel tired and/or un-refreshed.
I frequently feel sleepy during the day.
Daytime sleepiness interferes with my job.
Daytime sleepiness interferes with my enjoyment of life.
I have trouble remembering things.
I have difficulty concentrating at work.
People tell me that I am often cranky or irritable.
I sweat excessively during the night.
I wake up in the morning with a headache.
My mouth is dry when I wake up in the morning.
I am overweight.
I have been experiencing impotence.
I have regular sleeping hours.
I usually sleep for less than 7 hours (or more than 9 hours).
My job involves shift work or working unusual hours.
I don't have time to get the sleep I need.
4. INSOMNIA, DEPRESSION, ANXIETY
I have difficulty falling asleep at night.
It takes me more than 30 min to fall asleep.
I tend to worry about things and have trouble relaxing.
Thoughts racing through my mind often prevent me from falling asleep.
I wake up frequently during the night.
If I wake up at night, I have trouble falling back to sleep.
I regularly take something in the evening to help me sleep.
I suffer from pain during the night.
I suffer from depression.
I suffer from chronic anxiety.
I take tranquilizers or anti-depressants.
5. RESTLESS LEGS AND PERIODIC LEG MOVEMENTS
Sometimes I cannot keep my legs still.
I have a crawling sensation in my legs. The legs feel restless, numb, hot or cold. I have the need to move them.
I have been told that my arms or legs kick or jerk during sleep.
I am a restless sleeper.
I lack Iron.
6. NARCOLEPSY INDICATORS
I have experienced unexplained weakness somewhere in my body.
I have felt weakness in my body when I laugh or I am upset.
Sometimes just as I am falling asleep or as I am waking up, I feel that my muscles completely paralyze.
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