"Parkinson's Desease Sleep Evaluation Form"

ADVERTISEMENT
ADVERTISEMENT

Download "Parkinson's Desease Sleep Evaluation Form"

Download PDF

Fill PDF online

Rate (4.3 / 5) 33 votes
Page background image
Parkinson’s Disease Sleep Evaluation
Patient Name:
Doctor:
Start Date:
End Date:
Sleep Scale
Notes
1.
I have quality sleep through the night
1
2
3
4
5
2.
It’s difficult for me to fall asleep
1
2
3
4
5
3.
I wake up in the middle of the night
1
2
3
4
5
4.
I have restless arms/legs at night that disrupt sleep
1
2
3
4
5
5.
I fidget in bed
1
2
3
4
5
6.
I have upsetting dreams
1
2
3
4
5
7.
I have upsetting hallucinations while trying to sleep
1
2
3
4
5
8.
I get up at night to go to the bathroom
1
2
3
4
5
9.
I wake up because of numbing/tingling in my legs/arms
1
2
3
4
5
I have painful muscle cramps during the night
1
2
3
4
5
10.
I fall asleep during the day
11.
1
2
3
4
5
I feel sleepy when I wake up in the morning.
12.
1
2
3
4
5
13.
14.
15.
Additional Notes
Notes:
www.FreePrintableMedicalForms.com
Parkinson’s Disease Sleep Evaluation
Patient Name:
Doctor:
Start Date:
End Date:
Sleep Scale
Notes
1.
I have quality sleep through the night
1
2
3
4
5
2.
It’s difficult for me to fall asleep
1
2
3
4
5
3.
I wake up in the middle of the night
1
2
3
4
5
4.
I have restless arms/legs at night that disrupt sleep
1
2
3
4
5
5.
I fidget in bed
1
2
3
4
5
6.
I have upsetting dreams
1
2
3
4
5
7.
I have upsetting hallucinations while trying to sleep
1
2
3
4
5
8.
I get up at night to go to the bathroom
1
2
3
4
5
9.
I wake up because of numbing/tingling in my legs/arms
1
2
3
4
5
I have painful muscle cramps during the night
1
2
3
4
5
10.
I fall asleep during the day
11.
1
2
3
4
5
I feel sleepy when I wake up in the morning.
12.
1
2
3
4
5
13.
14.
15.
Additional Notes
Notes:
www.FreePrintableMedicalForms.com