Sleep History

History: 
[textarea name="History" memo ="what brings you to the sleep clinic?" rows=2 ]
 

SLEEP ROS: 
[checkbox name="SleepROS" value="Has snoring that bothers others|snores worse if laying on supine|has been told that they stop breathing in his/her sleep |has awakened feeling short of breath or choking|Has difficulty staying awake even if he/she has had a full night's sleep|sleepiness is a problem at work|Feels drowsy when driving, even with a full night's sleep|is concerned about ability to fall asleep |is concerned about the ability to stay asleep |has relied on sleeping pills or aids|does not look forward to bed time due to trouble sleeping|has thoughts that flood his or her mind that prevent sleep|wakes frequently in the night and cannot go back to sleep |wakes too early in the morning|worries and has trouble relaxing |is awake for more than 30 minutes before falling asleep|reads in bed |has a strong tendency to go to bed late and wake up late|has a strong tendency to go to bed early and wake up early|has a variable sleep pattern|has a shift work schedule|feels that he or she rarely gets enough sleep|walks in his or her sleep|talks in his or her sleep|has scary dreams or nightmares|eats in his or her sleep |grinds teeth|his or her legs are bothersome at night|has muscle cramps or charley horses that are bothersome at night|has crawling, tension, or twitching sensations in the legs at night|legs are bothersome at night but are better if they are moving|strange things happen to him or her at night|has weakness or loss of strength if a sudden strong emotion is experienced|experiences vivid, dreamlike states while falling asleep or shortly after|often feels paralyzed or short periods while falling asleep or shortly after."]


PAST MEDICAL HISTORY: 
[checkbox name="medicalconditions" value="Asthma|COPD|Pulmonary Hypertension|Airway abnormality or previous airway surgery|Hayfever/allergies|GERD|Peptic ulcers|Liver Disease|Diabetes|Thyroid disease|Adrenal disease|Seizures|Parkinson's disease|Alzheimers|Hypertension|Coronary Artery Disease/heart attack|Heart failure|A-fib/cardiac arrhythmia|chronic fatigue/fibromyalgia|developmental delay|depression"]
History:
what brings you to the sleep clinic?


SLEEP ROS:



PAST MEDICAL HISTORY:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.67, 3 form elements, 6 boilerplate words, 1 text areas, 2 checkboxes, 57 total clicks
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