Nash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:
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- Jeffry Goodwin
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1 Appointment Date: Arrival Time: *Please give at least 24 hour notice if you are unable to keep your appointment or need to reschedule. 1. Patients will need to bring pictured identification, insurance cards, and medication list. The technicians will be making a copy of these items and will return them to you. Take your medications as usual, unless your Physician instructs you otherwise. 2. Please shower before your arrival. This includes washing and drying hair, trimming beards and excessive facial hair. Do not apply perfumes, lotions, sprays, oils, conditioners, or gels. We must be able to get to specific places on the scalp. Those with braids and/or hair weaves may need to call to find out if the study can be done the way the hair is styled. Wigs should be removed for the study to be performed. Please remove all nail polish or expect at least one nail to be cleaned off. 3. No caffeine after 12:00 noon the day of your study. Please eat dinner before arriving for your test. 4. No naps the day of your study. This is very important for the quality of your sleep study. (For young pediatrics, please keep nap early in day and to a minimum.) 5. Pediatric patients under the age of 18 must have one parent/guardian stay with them for the entire night. Only one parent is allowed to stay. Pediatric patients will be put to bed as close to their home bedtime as possible. Adults will have lights out at their normal bedtimes. If your bedtime is after 10:00pm or 11:00pm, please let the Sleep staff know, so times can be adjusted for your study, if needed. The 8:00pm arrival time is to allow paperwork to be completed and the hooking up of the wires and equipment. Time is also allotted for those patients who will be treated with pressure equipment and need mask fitting. 6. Bring something comfortable to sleep in. You may bring your own pillow if you prefer. Pediatric patients are permitted to have bottles, pacifiers, diapers, pillows, blankets and toys to make them more comfortable. Ladies, please bring pajamas - avoid silk gowns. Gentlemen, please bring at least a pair of shorts. Jogging pants and t-shirts are acceptable for men and women as well. 7. Patients are typically awakened at their normal wake up times, depending upon when your study was initiated, and your normal sleep patterns. Please be aware your study may be delayed past 6:00am-6:30am for quality purposes. Please let the staff know of any concerns with this. 8. For insurance purposes, the sleep study must record for at least 6-7 hours. Patients may take a shower once disconnected. Your Sleep Specialists will offer a light healthy breakfast.
2 Thank you for choosing Nash Sleep Disorders Center for your upcoming Sleep Study. You are a valued customer and we want to provide you with excellent care before, during and after your study. Enclosed you will find a packet of information for your review. Please take the time to fill out this information prior to arriving for your sleep study and bring this packet with you the night of your study. If you have any questions or need help filling out these forms, please call us. Having this information completed will help facilitate our staff in providing you with very good care and minimize your wait times. It is important that your sleep study is scheduled for times when you normally go to sleep. If you normally sleep during the day or you work a second or third shift, it is imperative that you call our Sleep Center to let us know of any sleep patterns that are outside the normal sleep hours. This will ensure that you receive the best study and treatment possible. We are located on the Nash General Hospital campus in the Medical Arts Mall. This is the 2-story building behind Watson Eye Care Center. Please enter on the left side of the building, facing the hospital. Unless a scheduling time has been pre-arranged, you will need to arrive at 8:00 pm (7:30 pm for pediatric patients). For your safety and the safety of the staff, the doors to the building are locked after 5:00 pm. When you arrive at the door, there is a video intercom box on the column to the right of the door. Please push the button on the box and one of our staff members will greet you. He/she will then ask you to identify yourself. The doors will be unlocked and you may proceed to the elevator and come to the second floor. Your Sleep Technologist will meet and accompany you to your private room. Make sure you bring something comfortable to sleep in and please be sure to take your medications for the night. If you have questions regarding your medications please call us before your scheduled date. Also, since this is a medical test, no one will be allowed to stay in the room with you (exceptions: pediatrics and patients with special needs). If you require special assistance, please let us know in advance. In the morning, please feel free to take a shower and enjoy a light breakfast. Some of the selections we offer are coffee, tea, juice, cold cereal, yogurt, milk, fresh fruit and granola bars. Results of your sleep study typically take 4-5 business days. The Sleep Center will call you when these results are ready and will send them to your referring doctor s office. You are our number one priority and we aim to provide you with excellent care. If you are unable to keep your scheduled appointment, please call and let us know as soon as possible. Patients who do not show for their appointments, or fail to provide the Center with 24 hour notice for rescheduling may incur a $100 no show charge. THANK YOU FOR CHOOSING NASH SLEEP DISORDERS CENTER
3 Name: Home Phone: Date of Birth: Cell / Alternate Phone #: Age: Work Phone #: Sex: Address: Mailing Address: Referring Physician: Primary Physician: Please describe your main sleep problem: What makes it worse? For your main sleep interval during the week, what time do you usually: Get in bed? Fall asleep? Wake up for good? Example: Get in bed? 10:00pm Fall asleep? 10:45pm Wake up for good? 6:00am If you have a sleep time other than 10-11:00pm, or work 2 nd or 3 rd shift, please contact the Sleep Center for special scheduling (252) , M-F 8am-3:30pm. After falling asleep, do you wake multiple times during the night? How many hours of sleep do you usually get? How much do you nap during the day? Is your sleep very different on weekends or days off? Do you have trouble falling asleep or dozing off while driving? Have you had any driving accidents from falling asleep at the wheel? How much caffeine do you use (coffee, tea, soda, energy drinks)? How much alcohol do you drink? How much do you smoke? Is your bedroom dark? Quiet? Comfortable? Is your sleep disturbed often by family, noise, children, pets, etc.? Is your sleep disturbed by pain or medical problems? Occupation: Do you work second or third shift? Have your work hours changed recently? Have to travel much?
4 Do you now have? (Check all that apply) Nash Sleep Disorders Center Unintentional falling asleep during awake time Low motivation or energy Stroke Awake with gasping Weight loss (How much) Acid reflux Awake with choking Weight gain (How much) Breathing problems Awake with breath holding Restless sleep Morning headaches Loud Snoring Restless legs Sexual problems Interrupted breathing in sleep Leg movements Arthritis Fatigue Sleep walking Back pain Insomnia Sleep talking Hot flashes Unrefreshing sleep Nightmares Heart failure Excessive daytime sleepiness Leg jerks Heart problems Trouble falling asleep Bed wetting High blood pressure Awaking too early Sinus problems Diabetes Depression Thyroid problems Chronic pain Anxiety Throat surgery Frequent urination at night Mood problems Poor attention Poor concentration Poor memory MEDICATIONS (Please list all medications including herbs, vitamins and over-the-counter medications.)
5 ALLERGIES EPWORTH SLEEPINESS SCALE How likely are you to doze or fall asleep in the following situation? Use the following scale to choose the most appropriate number for each situation. 0 = no chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING Sitting and reading quietly Watching TV Sitting inactive in a public place (theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when time allows Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic EPWORTH TOTAL: ADDITIONAL INFORMATION:
Your physician has ordered a sleep study for you on. Your arrival time is scheduled for.
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Sleep Study Information
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Denver, CO Welcome Packet
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Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
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Health Benefits Employee Services HBE Preventive Health - Sleep Assessment Form Please bring your completed assessment form to your appointment. To schedule an appointment please call 505 844-HBES (4237).
PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
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Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
Associated Neurological Specialties and Sleep Disorder Center
Sleep Center Questionnaire Name: Sex: Age: Date: Date of Birth: Height: Weight: Neck Size: Primary Care Physician: Referring Physician: Main Sleep Issues/Complaints Trouble falling asleep Trouble staying
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
***Please review the following page to ensure you are properly prepared ***
REM Sleep Center d, TX 78 512-452-0004 opt.2 Appointment Information: Date: Time: Amount Due: *** If you need to cancel or reschedule your sleep study we require 2 business days notice. *** If you are
PATIENT DEMOGRAPHICS
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*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
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Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check
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Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
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Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D.
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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.
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EPWORTH SLEEPINESS SCALE
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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
Maintenance for Wakefulness Testing (MWT)
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PATIENT SLEEP QUESTIONNAIRE
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Psychological Sleep Services Sleep Assessment
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Sleep Center New Patient Questionnaire
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SLEEP STUDY CANCELLATION/ NO SHOW POLICY
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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
Date of Study: Arrive at: P.M.
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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
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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
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q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
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Welcome to the Koala Center for Sleep Disorders Your health is very important. We are honored to have the opportunity to join you on your wellness journey. In order to provide you with the comprehensive
What to expect during your stay at a Sleep Disorders Lab
What to expect during your stay at a Sleep Disorders Lab UHN Information for patients and families Read this information to learn: what a sleep study is what a CPAP titration study is how to prepare what
1101 Medical Arts Ave NE Bldg. #2 Albuquerque, New Mexico Office: * Fax: Website:
1101 Medical Arts Ave NE Bldg. #2 Albuquerque, New Mexico 87102 Office: 505-272-6110 * Fax: 505-272-6112 Website: http://hospitals.unm.edu/sdc/ Why do I need CPAP, AutoPAP or Bilevel? Appointment Information
493 Blackwell Road, Suite 317-A, Warrenton, VA
493 Blackwell Road, Suite 317-A, Warrenton, VA. 20186 Dear Sleep Study Patient, Attached is the patient questionnaire for your sleep study. Please complete and mail or fax the enclosed forms as soon as
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your
Your Journey Into Sleep-Level 1 Study/MSLT Sleep Disorder Centre
Your Journey Into Sleep-Level 1 Study/MSLT Sleep Disorder Centre Please read the following important information. If after reading these instructions you have any questions, concerns or require special
Patient Adult Information History
Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how
An Introduction to Identifying and Treating Sleep Disorders in Adults
An Introduction to Identifying and Treating Sleep Disorders in Adults REFERENCES/RESOURCES TOOLS & MEASURES: SLEEP DIARY: Carney, C., et al. (2012). The Consensus Sleep Diary: Standardizing prospective
Dear, Respectfully, United Sleep Centers SLEEP STUDY DATE: FEBUARY 26, 2015 AT OUR DOWNEY CENTER TIME: 10PM, PLEASE ARRIVE ON TIME
Sleep Study Instructions SLEEP STUDY DATE: FEBUARY 26, 2015 AT OUR DOWNEY CENTER TIME: 10PM, PLEASE ARRIVE ON TIME ADDRESS: 11411 BROOKSHIRE AVE SUITE 505 DOWNEY, CA Dear, Thank you for choosing us as
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
Treating Insomnia in Primary Care. Judith R. Davidson Ph.D., C. Psych. Kingston Family Health Team
Treating Insomnia in Primary Care Judith R. Davidson Ph.D., C. Psych. Kingston Family Health Team jdavidson@kfhn.net Disclosure statement Nothing to disclose A ruffled mind makes a restless pillow. ~ Charlotte
Improving Your Sleep During Your Hospital Stay
PATIENT & CAREGIVER EDUCATION Improving Your Sleep During Your Hospital Stay This information will help you improve your sleep during your hospital stay. Sleeping well at night can make you feel better
Tallahassee Memorial Sleep Center Patient Questionnaire
Tallahassee Memorial Sleep Center Patient Questionnaire Name _ Age Date Date of Birth Sex Height ft in Weight lbs Neck size inches (If known) Body Mass Index (BMI) (If known) Phone(s) (home) (work) (cell)
Intake Questionnaire
Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK=
Pediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
VERY IMPORTANT INFORMATION
Sleep Disorders Center VERY IMPORTANT INFORMATION Instructions for in-lab patients and HST (Home Sleep Test) patients Plan to arrive at the La Porte Hospital Emergency Room at the time specified in the
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