Sleep Questionnaire

Please complete all fields unless stated otherwise. Name NRIC Contact # Please enter at least one of HP or email. HP   email (format: name@domain.xxx)     Age     Sex Male Female Are you right-handed? Yes  No  Occupation  (State current level of education if schooling) Do you have any language impairments? No Yes, please specify  First language English Chinese Malay Tamil Others, please specify  Second language                   Must differ from "First Language". English Chinese Malay Tamil None Others, please specify  Do you have metallic implants? Yes  No  Not Sure If yes or not sure, what type? Vascular Clips Pacemakers Replacement Joints Skull Plates Braces/Dental Retainers Others. Please specify  Do you have a history of any neurological or psychiatric disorders? No Yes, please specify  Do you have any chronic medical illnesses? No Yes, please specify  Are you on any long term medications? No Yes, please specify  Do you suffer from any of the following problems?   1. Sleep Apnea Yes  No    2. Narcolepsy Yes  No    3. Periodic Leg Movements Yes  No    4. Excessive Daytime Sleepiness Yes  No    5. Insomnia Yes  No