DOS:       DOB: 

NAME:    Greenway ID#: 

Technician:    Location:    RM#:

1. What time did you go to sleep last night?
2. What time did you wake up today?
3. Did you take a nap today?
 YES
 NO
If so, for how long?
4. Did you have any caffeinated beverages today?
 YES
 NO
If so, how many?
5. Did you eat chocolate today?
 YES
 NO
If so, how much?
6. Did you drink alcohol today?
 YES
 NO
If so, how much?
7. What time was your last meal?
8. Did you smoke cigars/cigarettes?
 YES
 NO
If so, how many?
9. How stressful was your day today?
 More stress
 Less stress
 Typical day
10. How tired do you feel now?
 More tired
 Less tired
 Same as usual
11. What medications did you take tonight?