-Completed Sleep Questionnaire. - Payments (Self-Pay Patients) - Copy of order (if referred outside of The Neurology Center)

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1 Dear Sleep Patient, MEDICAL DIRECTOR & BOARD CERTIFIED SLEEP SPECIALIST Aman A. Savani, M.D. BOARD CERTIFIED SLEEP SPECIALIST Kalpana Hari Hall, M.D. Nabil Altememi, M.D. CHIEF EXECUTIVE OFFICER Anne D. Baccich DIRECTOR OF OPERATIONS Steven R. Long BUSINESS OFFICE The Summit Building th Street Suite 310 Silver Spring, MD Fax The Neurology Center for Sleep Disorders welcomes you to our facility. Enclosed in this packet, you will find general information regarding our sleep lab and tests performed as well as a questionnaire that should be completed prior to your sleep study. On the evening of your appointment, please bring the following: -Completed Sleep Questionnaire - Insurance Card(s) if you re new to NCPA and Photo ID for verification - Payments (Self-Pay Patients) - Copy of order (if referred outside of The Neurology Center) Once checked in, you will also be given an audio/video consent form that allows us to record and monitor you while you are sleeping. If your insurance requires a referral, please be sure that you have your primary care physician fax that to me PRIOR to your appointment. Some insurance plans will require a prior authorization that MUST be obtained prior to your study. We will attempt to obtain this authorization if required. In the event a study is denied by insurance, I will contact you before the evening of your study. Self-pay patients are required to make payment in FULL at the time of their scheduled study. We accept cash, all major credit cards and personal checks. Although we make every effort to confirm overall coverage from your insurance, we do not obtain specific benefits regarding deductibles and/or coinsurances. Feel free to contact your Benefits Coordinator or your insurance plan to obtain these figures. For scheduling matters regarding your sleep study appointment(s), please contact central scheduling at (301) and one of our specialists will gladly assist you. Appointments that are missed or cancelled with less than 24 hours notice will be subject to a $250 fee. Again, thank you for choosing The Neurology Center for Sleep Disorders and we hope you enjoy your experience. Sincerely, Emily Kittrell Office Manager 6931 Arlington Road, T-100 Bethesda, MD Fax

2 ABOUT US The Neurology Center for Sleep Disorders offers comprehensive diagnostic sleep disorder testing at our new office in Bethesda, Maryland. The Neurology Center for Sleep Disorders will continue the same excellent care The Neurology Center has been providing for our patients with neurological disorders for the last 45 years. We are dedicated to providing high-quality diagnostic evaluation and treatment of sleep disorders for the Washington, DC Metro area. Our new center is located in Bethesda near to NIH and National Naval Medical Center. We provide convenient, state of the art services to our patients, referring physicians and the community in the specialty of sleep medicine. We strive to provide excellent service in a first-class luxury setting to maximize patient comfort. MISSION STATEMENT Our mission is to provide comprehensive diagnosis and treatment of sleep and wake disorders to the people of the Washington DC metro area, while also adhering to the highest standards of medical care. We will provide our patients with a luxurious, safe and secure environment to undergo diagnostic treatment. OUR LOCATION Neurology Center for Sleep Disorders is located at 6931 Arlington Road, Suite T-100, in Bethesda, Maryland, close to NIH and National Naval Medical Center. We are convenient to Bethesda Metro station and the Capital Beltway. For local residents, we are across the street from Strosniders Hardware store and our building has it own lighted secure parking garage adjacent to the building. ENTERING THE BUILDING Because you ll be coming after-hours, the building will be locked for obvious security purposes. There is a callbox near the revolving doors however if you encounter issues entering the building, please call directly to our sleep technicians at (301) for assistance. We apologize in advance for any inconvenience this may cause.

3 FAQs What is a sleep study? A sleep study is a test that is used to diagnose sleep disorders. There are different types of studies designed for specific sleep disorders. Most studies occur overnight, but some also can take place during daylight hours. What should I expect once I arrive to the sleep lab? Once you arrive to the lab, the technician will be there to greet you and take you to your room. There you will be shown around and asked to change into your sleep attire. When you are ready the technician will come in and start applying sensors to your body. Be prepared to have sensors applied to you from head to toe. Sensors will be applied to your legs, face, and scalp. You will also be wearing belts on your chest, and your abdomen. Your heart will also be monitored during the test so be prepared to have electrodes attached to your body. Where do I park? Parking is free in the building s garage, but do not park in the assigned spaces inside the garage. You may be towed. Likewise do not park in the spaces outside the building as you may also be towed. How do I enter the building and the Sleep Center? Use the phone on the outside door to call the security service to gain access to building. In some cases the techs will greet you at the door. Take the elevator to the (T) terrace level and use the intercom on the wall next to the outside door. What kind of clothing should I bring? Make sure to bring comfortable clothing that you will sleep in for the night. Remember to keep it modest because the technician will be in your room applying electrodes to you. If I wear a hairpiece/wig, will this be a problem? Please remember not to wear any hairpieces or wigs. An essential part of the sleep study involves the placement of electrodes on your scalp and body. The technician must have easy access to place these electrodes. Can I put lotion on? No, do not use body lotion, body oil or makeup before your sleep study. An essential part of the sleep study involves the placement of electrodes on your scalp and body. Clean, dry skin and scalp will help ensure we obtain an optimum sleep study. Can I bring a book to read? Absolutely, bring a book or magazine if you plan on reading. Your room is equipped with a TV just in case you forget your book or choose to watch TV Arlington Road, T-100 Bethesda, MD Fax

4 FAQ s (continued) Can I take a shower in the morning? Yes, your room has a private bathroom with a shower. In fact, you should plan on showering to remove the electrode paste left in your hair. Towels, shampoo, and soap will be provided if you choose to take a shower, hair-dryers are also provided. Do you offer Wi-Fi? What if I need to make a phone call? Yes, we offer free Wi-Fi access. If you need to make an urgent outbound call, a phone is available. Where do I go to receive my CPAP machine and supplies? After your CPAP titration your physician will order you a CPAP machine and mask. The order will be forwarded to a medical supply company who specializes in CPAP equipment and this company should work with your insurance company on payment coverage issues. How long will the sleep study take? The hookup process will start in the evening between 9:30-10:30 pm and you will be leaving the next morning between 6-7am. What are some symptoms associated with sleep apnea? Loud snoring, choking and gasping during sleep, witnessed episodes, feeling tired when you wake up, excessive daytime fatigue, morning headaches, and inability to concentrate. Can I take my normal medications before I go to sleep? You may take your normal medications before you go to sleep. We ask that you hold off from taking your sleep medication until all the sensors are attached to you and you re ready for bed. Special needs patients. We have accommodations for patients who need to be accompanied by guardians or caregivers or use wheelchairs. Please inform us if you have any special needs so we can inform our technicians Arlington Road, T-100 Bethesda, MD Fax

5 Polysomnography (PSG) About the Test Your physician has ordered a sleep study, known as polysomnography (PSG). This is a routine sleep test that is used primarily for the diagnosis of sleep disordered breathing (SBD) or sleep apnea. What to Expect Once you arrive at our sleep center, the technician will be there to greet you and take you to your room. There, you will be shown around and asked to change into your sleep attire. When you are ready, and with your consent, the technician will enter your to apply sensors and electrodes necessary for the test. This process will take up to 30 minutes. Sensors will be applied to your legs, face, and scalp and flexible belts will be placed around your chest and abdomen in to get an accurate measure your respiratory effort. Our rooms are completely private, sound proof, and contain a full bathroom for your convenience. You will be monitored and video taped only while in bed and only when the study starts. After the Test Following the completion of study, the technician will remove the sensors/electrodes and you will be permitted to shower and get dressed. There will be a short questionnaire and survey for you to fill out before you leave. Per sleep center protocol, the technologist will not be permitted to discuss the findings of the study with you; the results will be available after the study has been interpreted by one of our board certified sleep specialists. IMPORTANT Please inform our staff if you have any special needs in order for us to provide for your accommodation. Phone Arlington Road, T-100 Bethesda, MD Fax

6 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) About The Test Your physician has ordered a CPAP Titration Study to be performed on you. The CPAP titration study is usually performed after a baseline sleep study (PSG) is done and you have been diagnosed with some form of sleep breathing disorder. The purpose of this study is to determine how to optimally treat your sleep apnea by using gentle air pressure generated by a CPAP machine and choosing the appropriate pressure and mask to eliminate all abnormal breathing events. What to Expect Similar to a baseline sleep study you will have electrodes or sensors applied to you with the difference being that the technician will also apply a facial mask for which your air pressure will be delivered. The technician may have you try on several masks to see which one you will be most comfortable with. During The Test After machine calibrations are done, the technician will ask you to fall asleep. The technician will adjust the CPAP machine from his/her computer during the night. Feel free to call your technician at any time if you are having difficulties during your titration so the technician can assist you. Other forms of Non-Invasive Therapy BI-LEVEL POSITIVE AIRWAY PRESSURE (BI-PAP) About The Test Phone Arlington Road, T-100 Bethesda, MD Fax

7 BIPAP therapy is another form of non-invasive therapy that can be used to eliminate sleep disordered breathing. BIPAP (Bi-level Positive Airway Pressure) machines are non-invasive machines that provide a person with a higher pressure when a person breathes in and then lowers the pressure when the person tries to breathe out. The two pressure settings are IPAP (inhalation pressure), and EPAP (exhalation pressure). The EPAP allows the person to be able to breathe out at a lower pressure. The BIPAP Auto SV is another form of non-invasive therapy. The Bi-PAP Auto SV is intended to provide non-invasive ventilator support to treat adult patients with sleep apnea and respiratory insufficiency caused by central and/or mixed apneas and periodic breathing. SPLIT NIGHT SLEEP STUDY About The Test During a split night study a patient is being evaluated for sleep apnea. The first part of study will consist of a routine sleep study if the is significant sleep apnea or abnormal breathing activity in the 3-4 hours of the study, the technician wake up the patient, place the CPAP mask on the patient and turn on the CPAP unit. From there the technician will determine how to optimally treat your sleep apnea by choosing the appropriate pressure and mask to eliminate all abnormal breathing events. After all the Tests Once the test is over the technician will removed the sensors/electrodes and you are free to take a shower at that time, there will be a short questionnaire and survey for you to fill out before you leave. The technologist will not discuss the findings of the study with you; the results are not available until the interpretation by our sleep physicians is complete. IMPORTANT Please inform our staff if you have any special needs in order for us to accommodate. Phone Arlington Road, T-100 Bethesda, MD Fax

8 Multiple Sleep Latency Test (MSLT) About The Test Your physician has ordered a Multiple Sleep Latency test (MSLT) to be preformed on you. The purpose of this test is to quantify the degree of daytime sleepiness that you may be experiencing. This test is usually done in conjunction with an overnight sleep study (PSG) What to Expect This test consists of a series of short naps during the day so expect to be in our facility for the entire day. There will be at least 4 naps with a possibility of a 5 th nap. The last nap could start as late as 3:00 p.m., therefore we advised you to bring a lunch as you will be with us throughout the afternoon. We will provide you with a very comfortable room and there is also a patient lounge with a small refrigerator for your use, feel free move about the center to stretch your legs between naps. After the Test Once the test is over the technician will removed the sensors/electrodes and you are free to take a shower especially if you been all night, there will be a short questionnaire and survey for you to fill out before you leave. The technologist will not discuss the findings of the study with you; the results are not available until the interpretation by our sleep physicians is complete. Parking All patients will be charged $10 for parking during the day so please remember to bring money for parking. The sleep lab does not validate parking. IMPORTANT Please inform our staff if you have any special needs in order for us to accommodate. Phone Arlington Road, T-100 Bethesda, MD Fax

9 Home Sleep Study About the Test Your physician has ordered a home sleep study. This is a sleep study that is conducted in your own home. What to Expect You will have to pick up the unit at our sleep center located at 6931 Arlington Rd Suite T100 Bethesda, MD A sleep technologist will greet you and show you how to use the machine and apply various sensors through your body. If you run into any problems after hours please contact (301) for assistance. During the following morning you will then remove all the sensors and place them back into the bag and return the equipment back to the sleep center. If the equipment is not returned to the sleep center the following day, you will be charged a missed appointment fee of $ If you pick up the equipment on Friday you will be required to return the equipment on Monday. After the equipment has been returned the study will be reviewed by a sleep physician. If you need to make a follow up appointment with one of our sleep physicians please call (301) and we will be happy to schedule you. Phone Arlington Road, T-100 Bethesda, MD Fax

10 DIRECTIONS TO THE NEUROLOGY CENTER FOR SLEEP DISORDERS 6931 ARLINGTON ROAD, SUITE T-100 BETHESDA, MARYLAND From the North Take Interstate 270 south to Rockledge Drive (exit 1) Turn left on Rockledge Drive. Turn right onto Old Georgetown Road (Rt. 187) Follow Old Georgetown Road about 4 miles to Arlington Road Turn right onto Arlington Road. Turn left into 6931 Arlington Road driveway entrance (park in the garage to left) From the South Take Wisconsin Avenue (Rt. 355) (past Friendship Heights) Turn left onto Bradley Blvd. (Rt. 191) Turn right onto Arlington Road Turn right at the first driveway entrance at 6931 Arlington Road (park in the garage to left) From the East Go west on the Capital Beltway (I-495/ outer loop) to Connecticut Avenue (Rt. 185), south towards Washington, DC Follow Connecticut Avenue south to Bradley Lane Turn right onto Bradley Lane. Follow Bradley Lane across Wisconsin Ave. to Arlington Road. Turn right onto Arlington Road Turn right at the first driveway entrance at 6931 Arlington Road (park in the garage to left) From the West Go east on the Capital Beltway (I-495/ inner loop) to Old Georgetown Road (Rt. 187), south towards Bethesda Follow Old Georgetown Road south about 4 miles to Arlington Road Turn right onto Arlington Road Turn left into 6931 Arlington Road driveway entrance (park in the garage to left) Parking Please park in unassigned spaces only. Parking is free between 7 pm and 7 am nightly. Google Maps 96, ,18z/data=!4m2!3m1!1s0x89b7c97e95223bad:0x b120d9abc 6931 Arlington Road, T-100 Bethesda, MD Fax

11 Questionnaire Patient Name: Sex: Age: Date: Occupation: Referring Physician: Family physician (PCP): Marital status: {} Single {} Married {} Divorced {} Widowed Please complete the following questionnaire. Sleep Complaints: {} Trouble sleeping at night For how long? {} Being sleepy all day For how long? {} Snoring For how long? {} Other, explain Sleep Pattern Typical Bedtime: Typical amount of time it takes to fall asleep: Typical amount of time it takes to back to sleep after an awakening: Typical number of awakenings per night: Typical wake up time: weekday weekend 1 P a g e

12 Typical time you get out of bed: weekday weekend Total amount of sleep per night: Number of naps per day: Please check all of the following statements that are true about your sleep: Sleep Habits {} I usually watch TV or read in bed prior to sleep {} I often travel across 2 or more time zones {} I drink alcohol prior to bedtime {} I smoke prior to bedtime or when I awaken during the night {} I eat a snack at bedtime {} I eat if I wake up during the night {} I typically wake up from sleep to go to the bathroom {} I have trouble falling to sleep {} I often wake up during the night {} I am unable to fall back to sleep easily if I wake up during the night {} I think a lot when I am trying to fall asleep {} I have nightmares as an adult {} I experience a tingling sensation in my legs when I try to fall asleep {} I sweat a great deal during sleep {} I cannot sleep on my back Breathing {} I have been told I stop breathing while I sleep {} I wake up at night choking, or gasping for air {} I have been told I snore 2 P a g e

13 {} I have been told I only snore when I am sleeping on my back {} I have been awakened by my own snoring Restlessness {} My legs and arms are uncomfortable when I lie down {} I have to move my legs or walk to relieve the uncomfortable feelings in my legs {} I am a restless sleeper {} I have been told that I kick or jerk my legs and/or arms during sleep {} I have a hard time falling asleep because of my leg movements {} I have talked in my sleep as an adult {} I have walked in my sleep as an adult {} I grind my teeth in my sleep Daytime Sleepiness {} I take daytime naps {} I have a tendency to fall asleep during the day {} I have fallen asleep while driving {} I have been in auto accidents because I have fallen asleep while driving {} I fall asleep while watch TV {} I fall asleep during conversations {} I have had injuries because of my sleepiness {} I have had hallucinations when falling asleep or waking up. {} I have had an inability to move while falling asleep or waking up Habits Do you smoke? {} Yes {} No If yes: How much? For how long? 3 P a g e

14 Do you drink alcohol? {} Yes {} No If yes: How often? For how long? Social History {} Sleep Alone {} Share a bed with someone {} Share a bedroom, but have separate beds {} Share a home, but have separate rooms Employment Status: {} Employed {} Unemployed {} Retired {} My job requires that I drive me vehicle {} I work with dangerous equipment {} I am a shift worker {} I am currently a student Medical History Vital statistics What is your: Height? feet inches Weight? pounds Neck Size: What was your weight one year ago? pounds Five years ago? pounds Current Medications Medication Dose # Times Per Day 4 P a g e

15 Allergies: Past Sleep Evaluation and Treatment {} I have had a previous sleep disorder evaluation {} I have had a previous overnight study {} I have had a daytime nap study {} I have been prescribed a CPAP or BIPAP machine for home use {} I have had surgical treatment for a sleep disorder {} I have been prescribed medication for a sleep disorder {} I have been treated for a sleep disorder Past Medical History {} Hypertension (high blood pressure) {} Hepatitis/jaundice {} Heart Disease {} Hearing Impairment {} Diabetes {} Depression or severe anxiety {} Stomach or colon problems {} Alcoholism {} Lung problems/copd/asthma {} Chemical dependency or abuse {} Reflux {} Fibromyalgia Female {} Stroke {} Premenstrual syndrome {} TIA Light Stroke {} Menopause {} Blackouts {} Seizures Male {} Back or joint problems {} Prostate problems {} Cancer {} Erectile dysfunction/impotence {} Thyroid cancer 5 P a g e

16 List all other past medical problems and dates: List Surgeries and the year Check any of the following symptoms you have had in the past 12 months Yes No Yes No {} {} Frequent headaches {} {} Frequent heartburn/indigestion {} {} Fainting or passing out {} {} Abdominal pain {} {} Sudden loss of vision {} {} Frequent constipation {} {} Inability to speak {} {} Frequent diarrhea {} {} Hearing loss {} {} Rectal bleeding/black stools {} {} Hoarseness {} {} Difficulty urinating/incontinence {} {} Nosebleeds {} {} Blood in urine 6 P a g e

17 {} {} Cough for more than 2 weeks {} {} Urinating more than 2 times per night {} {} Coughing up blood {} {} Pain in joints or bones {} {} Shortness of breath {} {} Unusual bruising or bleeding {} {} Swelling in feet or ankles {} {} Epilepsy/seizures {} {} Chest pain, pressure {} {} Change in wart, mole or skin growth {} {} Irregular heartbeat {} {} Weight loss of more than 5-10 pounds {} {} Difficulty swallowing food Family History Has an immediate relative had any of the following? Yes No Relation Yes No Relation {} {} Cancer {} {} Stroke {} {} Diabetes {} {} Anxiety/Depression {} {} Hypertension {} {} Sleep apnea {} {} Heart Disease {} {} Narcolepsy {} {} Thyroid Disease {} {} Other Using the Answer Key below, please circle the number that best applies to your life over the past 6 months Answer Key 1- Never 2- Rarely 3- Sometimes 4- Usually 5- Always I have trouble falling asleep I wake up often during the night At bedtime, thoughts race through my head At bedtime, I feel sad and depressed When falling asleep, I feel paralyzed (unable to move) When falling asleep, I have restless legs I wake up suddenly gasping for breath, unable to breath At night my heart pounds, beats fast, irregularly P a g e

18 I sweat a great deal at night I have a lot of nightmares I am unable to move after a nap I have hallucinations as I wake up in the morning I have slept for several days at a time I have been unable to sleep for several days I think I have insomnia I am sleepy during the day and struggle to stay awake I have fallen asleep talking to someone, or eating I have trouble doing my job due to fatigue I often let someone else drive due to my fatigue I have high blood pressure I have less desire or interest in sex I have considered or attempted suicide I smoke tobacco within two hours before bed I feel my nose is blocked up when I am trying to sleep My snoring is worse while I am on my back P a g e

19 Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? Rate each description according to your normal way of live in recent times. Even if you have not been in some of these situations recently, try to determine how sleepy you would have been. Use the following scale to choose the best number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Situation Sitting and reading Watching TV Sitting inactive in a public place Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch without alcohol Sitting in a car, while stopped for a few minutes in traffic Chance of dozing Total: 9 P a g e