THE SLEEP EDUCATION CONSORTIUM (S.E.C.) is excited to announce the A.W.A.K.E. GREATER HOUSTON monthly patient advocacy group for individuals suffering from obstructive sleep apnea and other sleep disorders.
A.W.A.K.E. is a national patient advocacy group sponsored by the American Sleep Apnea Association. Its mission is to increase awareness and education about 0bstructive sleep apnea.

Sleep Education Consortium, Inc.
2201 W. Holcombe Blvd., #325
Houston, TX 77030
Phone: (281)-269-7881
email: houstonsleep@gmail.com

Sleep Education Consortium, Inc.

A 501(c)3 Non-Profit Organization dedicated to providing educational opportunities for medical professionals and the general public on sleep and sleep disorders.

 

Sleep Questionnaire

Please take a few minutes to complete our online sleep survey so we can learn more about the public's sleep habits. All information is confidential and reviewed by Dr. Simmons.

In order to assist us in processing forms fill in all fields.
If a field does not apply in your circumstance, please enter "N.A."
Please do NOT press your "Enter" key while filling out this form.

 

If you are experiencing problems viewing or submitting this form a printable version in .PDF format is available here.

 

 

M F

ft. - in.

lbs.

 

This questionnaire is used for all of Dr. Simmons programs: please choose the clinic location you wish the response to be directed to (mandatory):

 

Houston Medical Center
Sugar Land
The Woodlands
Conroe
Austin

Yesor No
Yes or No

If you are currently on CPAP or BiPAP then your responses below should be in the context of how you are while using your treatment.

 


Yes or No

Yes or No
Yes or No

Yes or No

Yesor No


Yesor No

Yes or No
Rarely (25%)   | Half the time (50%) |  Most of the time (75% or more)

Yes or No

Yes or No

Yes or No
Mild   | Moderate   | Severe

Yesor No
Throughout the night Frequently Occasionally

Not Applicable Yes or No

12. Check those that apply to you:

headache excessive sweating heart burn chest pain clenching jaws (or grinding teeth) in sleep choking or gasping drooling on the pillow bed wetting (loss of bladder control) nasal congestion on awakening (which was not present when you went to bed)

Yesor No




Within the first 90 minutes first 3 hrs last 3 hrs of sleep

Yes or No

Yes or No

Yes or No

Yesor No

17. What is your daily consumption of:

Yes or No

Yes or No
Yes or No

Rank how likely it would be for you to become drowsy (like you’re going to fall asleep, rather than just feeling tired) during the day in the following situations:

0 = never become drowsy
1 = rarely become drowsy
2 = frequently become drowsy
3 = always become drowsy

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

My sleep problems are:

My other medical problems are:

My medications are:

Yes or No
If yes, when and where?

Yes or No

Yes or No

Yes or No

Yesor No

Yes or No
If No, then please state approximately when and where prior contact took place: (also note if you were directed to this page from our office while providing your personal information.)

YOU MUST ENTER THE SECURITY WORDS IN THE BOX BELOW BEFORE SUBMITTING THE FORM.