Your appointment is scheduled for at with Dr. Dimitri Markov.
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1 Jefferson Sleep Disorders Center Dear prospective patient: We thank you for choosing the Jefferson Sleep Disorders Center, At the Navy Yard. 3 Crescent Drive, in Suite 100 (on site parking) We are happy to be involved in your care. Please complete the enclosed forms and initial questionnaire and bring them with you on the day of your appointment. We understand this paperwork is extensive and will take a sufficient amount of time to complete. However it is very helpful for your sleep physician and will assist with your care. If you have any questions, please call us. Your appointment is scheduled for at with Dr. Dimitri Markov. WHAT TO BRING WITH YOU TO THE VISIT It is IMPERATIVE that you complete all enclosed forms PRIOR to your visit and that you BRING THEM WITH YOU to your initial visit. If you have had sleep studies before, please bring the results of all of your prior sleep studies with you. If you have already been diagnosed with sleep apnea, and have a CPAP machine, please bring your CPAP machine with you. If we do not already have them, please bring results of any pertinent tests performed over the past year, such as blood labs, EKG, x-rays, etc. WHAT TO EXPECT ON THE DAY OF YOUR VISIT A sleep specialist doctor will review your prior medical records, interview you, and perform a brief noninvasive physical examination. Please arrive 15 MINUTES early for your appointment. Failure to do so may cause us to reschedule your appointment. If you need to reschedule, please call INSURANCE At the time that you scheduled your appointment, the scheduler informed you of all referrals required by your insurance carrier. Please remember that most HMO patients must have a referral on file or a copy of the referral. Please bring your insurance card and driver s license to your visit. Co-payments are collected at the time of your visit. The following is a list of provider numbers that will allow you to obtain your referral: KEYSTONE EAST AETNA Cigna Health Springs (Bravo) Dr. Markov Sleep Medicine HOME OF SIDNEY KIMMEL MEDICAL COLLEGE CS
2 What is the main problem for which you are coming to the Jefferson Sleep Disorders Center? Do you snore? M Yes M No Do you wake others as result of your snoring? M Yes M No Do you snore louder on your back than your side? M Yes M No Do you have gaps or pauses in breathing during sleep? M Yes M No Do you wake from sleep with choking or gasping? M Yes M No Do you wake with a sour taste in your mouth? M Yes M No Do you wake with dry mouth? M Yes M No Do you wake with a headache? M Yes M No Do you kick or leg twitch during sleep? M Yes M No Do you have leg discomfort prior to or after falling asleep? M Yes M No Do you experience body rocking during sleep? M Yes M No Do you ever experience head banging/rocking during sleep? M Yes M No Do you fall out of bed during sleep? M Yes M No Have you ever experienced other body movements during sleep? M Yes M No Do you experience bed wetting during sleep? M Yes M No Do you experience loss of bowel control during sleep? M Yes M No Have you ever experienced sleep walking? M Yes M No Have you ever experienced vivid dreams? M Yes M No Have you ever experienced night terrors? M Yes M No Have you ever experienced sleep disturbed by headaches? M Yes M No Have you ever experienced paralysis during or just prior to sleep? M Yes M No Have you ever experienced sudden loss of muscle control? M Yes M No Jefferson Sleep Disorders Center page 1 of 5 FORM (REV.11/17) CS
3 Have you ever experienced sudden weakness following an emotional experience? M Yes M No Do you experience teeth grinding during sleep? M Yes M No Do you experience teeth clenching during sleep? M Yes M No Do you ever experience difficulty falling asleep? M Yes M No Do you experience difficulty staying asleep (nocturnal awakenings)? M Yes M No Do you experience restless and disturbed sleep? M Yes M No Do you experience waking early in the morning even when unnecessary? M Yes M No Have you ever experienced feeling unrefreshed after a full night s sleep? M Yes M No Do you take day time naps? M Yes M No Do you fall asleep involuntarily during the day or evening? M Yes M No Do you fall asleep or nod off while driving? M Yes M No Have you ever experienced accidents as a result of falling asleep during driving? M Yes M No Do you fall asleep while reading or watching TV? M Yes M No Do you fall asleep during conversations? M Yes M No Do you fall asleep at work? M Yes M No Do you experience inability to nap even after trying? M Yes M No Do you sleep worse while away from home? M Yes M No Do you do shift-work? M Yes M No Do you sleep in late on weekends or days off from work? M Yes M No Do you travel across times zones? M Yes M No What time do you go to bed? How long does it usually take you to fall asleep? Number of times you awaken you a typical night? Typical length of each awakening? Time of your final awakening? Time you finally get out of bed? The length of time it takes you to feel alert after getting out of bed? The time(s) when you again feel sleepy during the day? The typical length of time it takes you to feel sleepy during the day? How many naps you take during a typical day? The typical length of each nap? Do you dream during naps? Are naps refreshing? Time you would go to bed given the opportunity? Number of naps you would take, if given the opportunity? Do you sleep alone? M Yes M No Jefferson Sleep Disorders Center page 2 of 5 FORM (REV. 11/17) CS
4 Number of regular sodas (glasses) per day: Number of regular tea (cups) per day: Number of regular coffee (cups) per day: Number of chocolate (pieces) per day: Number of beer (ounces) per day: Number of liquor (ounces) per day: Please list all current medications and dosage or write No Current Medications. Please list past sleep related medications. Please list all allergies to medications or write no known drug allergies. Jefferson Sleep Disorders Center page 3 of 5 FORM (REV. 11/17) CS
5 Please describe your occupation: Please describe your leisure activities: Please indicate if you have had difficulty in any of the following areas. Please describe the difficulty Please make your choice with a check mark Never In the Past Currently Head M M M Eyes M M M Ears M M M Nose M M M Throat M M M Neck M M M Back M M M Chest M M M Heart M M M Lungs M M M Liver M M M Kidney M M M Thyroid Gland M M M Arms or Legs M M M Joints M M M Skin M M M Sexual Function M M M Vision M M M Speech M M M Urination M M M Bowel Movements M M M Jefferson Sleep Disorders Center page 4 of 5 FORM (REV. 11/17) CS
6 Fatigue Severity Scale (FSS) The FSS questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and circle a number from 1-7 based on how accurately it reflects your condition during the past week and the extent to which you agree or disagree that the statement applies to you. During the past week, I have found that: Disagree Agree My motivation is lower when I am fatigued Exercise brings on my fatigue I am easily fatigued Fatigue interferes with my physical functioning Fatigue causes frequent problems for me My fatigue prevents sustained physical functioning Fatigue interferes with carrying out certain duties and responsibilities Fatigue is among my three most disabling symptoms Fatigue interferes with my work, family, or social life FSS Score: The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Sitting and reading Watching TV Sitting inactive in a public place Passenger in a car for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch with no alcohol In a car, while stopped for a few minutes in traffic ESS Score: Patient Signature: X Date: FOR PHYSICIAN OFFICE USE ONLY I certify that I have reviewed and evaluated pages 1 through 7 with the above named patient. Physician Signature: X Date: Time: M Karl Doghramji, MD M Dimitri Markov, MD M Ritu Grewal, MD M Zhanna Fast, MD Jefferson Sleep Disorders Center page 5 of 5 FORM (REV. 11/17) CS
7 Getting to the Jefferson Sleep Disorders Center at the Navy Yard By Car From Center City Philadelphia Take Broad Street south to the Navy Yard. Enter the Navy Yard and turn left at first light onto We are located on the first floor of 3 Crescent Drive, in Suite 100. From Delaware and Points South of Philadelphia Take I-95 North to Exit 17 (Broad Street/Pattison Avenue). Turn left at first light (Zinkoff Boulevard) and make immediate left onto Broad Street. Get in right lane (avoid the entrance to I-95) and follow Broad Street into the Navy Yard. From New Jersey via Walt Whitman Bridge Cross the Walt Whitman Bridge. After the toll booth, take Exit 349 (Broad Street/Sports Complex). Turn left at the first light onto Broad Street. Follow Broad Street approximately 1 mile to the Navy Yard. From Points North Take I-95 South to Exit 17 (Broad Street/Pattison Avenue). Stay to the left. Cross over Broad Street and then make a left onto Broad Street at the second light. By Public Transit From Center City You now have the option to utilize public transportation with access to the Navy Yard via free bus routes. The Navy Yard Express Shuttle runs from 10th and Filbert Streets to the Navy Yard, and The Navy Yard Loop Shuttle runs all day from AT&T Station to the Navy Yard. Visit navyyard.org for updated schedules and maps. Once you exit the bus, walk a few hundred feet to 3 The entrance to Jefferson at the Navy Yard is located at the back of the building. We are on the first floor of 3 Crescent Drive, in Suite 100. Parking at Jefferson at the Navy Yard Free parking is available. The parking lot is located behind 3 After driving through the Navy Yard gates, make your first left onto Turn right at the stop sign and make the next left into the parking lot. Walk to the back entrance of the building from the parking lot and go through the doors. We are in Suite 100, the first door on your right. S. Broad Street Zinkoff Blvd S. Broad Street Wachovia Center From Western Suburbs Take 476 South to I-95 North. Take I-95 North to Exit 17 (Broad Street/Pattison Avenue). Turn left at the first light (Zinkoff Boulevard) and make an immediate left onto Broad Street. Get in right lane (avoid the entrance to I-95) and follow Broad Street into the Navy Yard. N Langley Ave Navy Yard Entrance/Gate Crescent Drive 1 Crescent Drive Parking League Island Blvd 13th Street 3 Crescent Drive Parking CS
Your appointment is scheduled for at with:
Dear prospective patient: We thank you for choosing the, At the Navy Yard. 3 Crescent Drive, in Suite 100 (on site parking) 215-503-3300 We are happy to be involved in your care. Please complete the enclosed
Your appointment is scheduled for at with Dr. Karl Doghramji.
Jefferson Sleep Disorders Center 443 Laurel Oak Road, 1st Floor Voorhees, NJ 08043 T 856-741-0122 F 856-741-0121 Dear prospective patient: We thank you for choosing the Jefferson Sleep Disorders Center
Sleep History Questionnaire
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Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
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Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
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PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
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PEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
EPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
Please complete this questionnaire before your appointment.
Date completed: Please complete this questionnaire before your appointment. Name: Occupation: Age: Birth date: Gender: M / F Height: Weight: Weight in High School: Neck Size: in. Ethnicity: Hispanic or
Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
Dear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology.
Dear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology. You should read through this package and complete all indicated areas. Some paperwork is related to your health history, some
Original Sleep Hygiene Rules*
Original Sleep Hygiene Rules* 1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing time in bed a bit seems to solidify sleep; excessively long times
Your Sleep Study will begin the night of at 8 p.m. and will end the following day between 6 a.m. and 7 a.m.
SLEEP DISORDERS CENTER St. Joseph Mercy Ann Arbor 5305 Elliott Drive, Ypsilanti, MI 48197 734-712-2276 / Fax 734-712-2967 Sleep Study Information Dear _, Your Sleep Study will begin the night of at 8 p.m.
Room # Critical Care & Pulmonary Consultants, P.C.
Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate
Help I Have Problems with My Sleep!
Help I Have Problems with My Sleep! Over An 85 Year Lifespan Sleep 31% Work 21% Exercise 1% Food and Drink 11% Sleep Is Important! You can survive without food for up to 2 months Without water 3-5 days
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
SLEEP CENTER OF KENTUCKIANA 7926 Preston Hwy. Suite 200 Louisville, KY Tel: (502) Fax: (866)
Patient Information First Name MI Last Name Age Date of Birth Social Security # Work Sex Male Female Home Phone Cell Phone Next of Kin Relation Phone Number Address City State Zip Code Employer Employer
Sleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?
Onslow Medical Specialties Clinic Lung Diseases & Sleep Disorders Clinic Pulmonary Function Test/ CardioPulmonary Exercise Test/ Thoracic Ultrasound Methacholine Challenge Test/ Video-Flexible Laryngoscopy/
Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
Patient Information Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305 Home Phone: Cell Phone: Last Name: First Name: MI Mailing Address: APT City/State/Zip Sex: Male Female Birthdate:
Facial Problem(s) Questionnaire
Facial Problem(s) Questionnaire Full Legal Name: _ Birth Date: Referred by: Referring Dr s Phone#: Referring Dr s Email address: _ Christopher M. Anderson, DMD 1225 Johnson Ferry Road Suite 660 Marietta,
Sleep Questionnaire. If yes, what? If yes, how would you describe it? Please explain? If yes, what times are these?
THE ADRENAL THYROID REVOLUTION Professional Mastermind Aviva Romm MD Sleep Questionnaire Sleep is important for musculoskeletal healing and for healthy immune function, mood, cognitive and brain function,
Date of Study: Arrive at: P.M.
Date of Study: Arrive at: P.M. Depart at 5: AM (Note: Sleep technicians leave the premises at 6 AM) Please notify the Palos Pulmonary staff in advance if you require any special assistance / accommodations
Home Sleep Testing Questionnaire
Home Sleep Testing Questionnaire Patient Name: DOB: / / Gender: Male Female Study Date: / / Marital Status: Married Cohabitate Single Divorced Widow/Widower Email: Phone: Height: Weight: Neck Size: What
DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
PATIENT INFO SLEEP VISIT
Pulmonary Associates of LVPG A practice of Lehigh Valley Physician Group 1250 S. Cedar Crest Blvd., Suite 205, Allentown, PA 18103 1770 Bathgate Drive, Suite 403, Bethlehem, PA 18017 610-439-8856 (phone)
Sleep Disorders Center of Santa Maria
SLEEP QUESTIONNAIRE Patient Name: Sex: Date of Birth: Occupation: Usual Work Hours/Days: Referring Physician: Family Physician: Marital status: Single Married Divorced Widowed Please complete the following
SLEEP STUDY CANCELLATION/ NO SHOW POLICY
Olusegun Oseni, MD F.C.C.P. 945 Hilltop Dr, Ste 101 Weatherford, Texas 76068 Phone: 817-594-9993 Fax: 817-594-9915 SLEEP STUDY CANCELLATION/ NO SHOW POLICY Dear Patient: We understand that emergencies
Polysomnography Patient Questionnaire
Polysomnography Patient Questionnaire Date Medical Record # Demographics: Patient Name Date of Birth Address_ Home Phone Work Phone Cell Phone Height Weight Please complete each section of this questionnaire,
Southwestern Neuroscience Institute Neurology Seizure and Sleep Clinic M: F:
Patient Pre-Study Instructions Please read the following information below to assist us in making your overnight study more comfortable, as well as maximizing the quality of our data collection. Before
The Medical Center Sleep Center
The Medical Center Sleep Center Date: / / Name: Age: (First) (M.I.) (Last) Address: (Street / P.O. Box) (City) (State) (Zip) (County) Phone: Home ( ) Work ( ) Date of Birth: / / Education: Marital Status: