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1 PATIENT INFORMATION Dear Patient: Sleep prblems are extremely cmmn. Public health and safety are threatened by the increasing prevalence f bstructive sleep apnea, which nw afflicts at least 25 millin adults in the U.S., accrding t the Natinal Healthy Sleep Awareness. Insmnia may be present in 15% t 20% f the ppulatin n a chrnic basis. All f these disrders affect daytime wakefulness t a different degree in each persn. Fr instance, sme peple with mderately severe sleep apnea claim t have little r n symptms f daytime sleepiness, while individuals wh nly manifest snring during sleep may feel terribly sleepy during the day. Yu shuld be aware that any nighttime sleep disturbance may cause daytime drwsiness and therefre culd impair yur ability t perate heavy machinery (especially a mtr vehicle). Yu shuld nt expse yurself r thers t harm because f yur ptential drwsiness. Obviusly, each persn must use his/her best judgement t determine if placing himself/herself in a particular setting (e.g. driving a car, r wrking at heights) might lead t harm t himself/herself r t thers. Fr ur prtectin, we require verificatin that yu have received this ntice. Therefre, please sign belw. Thank yu, St. Charles Sleep Center I hereby acknwledge the freging risks and with full knwledge d cnsent t vluntary participatin in the sleep lab prgram. Patient Signature: Date: Ref # 4180, Ver. 2

2 Patient Care Team Wh is invlved in yur care? This frm has been created t help all prviders invlved in yur care knw what additinal supprt systems yu have currently. Name: City/State: Phne: Cmmunity Health Wrker (CHW) Hme Health Care Specialist Nurse Care Crdinatr (RNCC) Behaviral Health Cnsultant Persnal Caregiver (friend, family, etc) Name: City/State: Phne: Cmmunity Health Wrker (CHW) Hme Health Care Specialist Nurse Care Crdinatr (RNCC) Behaviral Health Cnsultant Persnal Caregiver (friend, family, etc) Name: City/State: Phne: Cmmunity Health Wrker (CHW) Hme Health Care Specialist Nurse Care Crdinatr (RNCC) Behaviral Health Cnsultant Persnal Caregiver (friend, family, etc) Name: City/State: Phne: Cmmunity Health Wrker (CHW) Hme Health Care Specialist Nurse Care Crdinatr (RNCC) Behaviral Health Cnsultant Persnal Caregiver (friend, family, etc) Name: City/State: Phne: Cmmunity Health Wrker (CHW) Hme Health Care Specialist Nurse Care Crdinatr (RNCC) Behaviral Health Cnsultant Persnal Caregiver (friend, family, etc)

3 Name PRE-EPWORTH SCALE Date Yur Age Yur Sex: Male Female Hw likely are yu t dze ff r fall asleep in the fllwing situatins in cntrast t feeling just tired? This refers t yur usual way f life in recent times. Even if yu have nt dne sme f these things recently, try t wrk ut hw they wuld have affected yu. Use the fllwing scale t chse the mst apprpriate number fr each situatin. Ref # 4178, Ver. 1 0 = Wuld never dze 1 = Slight chance f dzing 2 = Mderate chance f dzing 3 = High chance f dzing SITUATION: 1. Sitting and reading Watching TV Sitting, inactive in a public place (e.g. a theater r a meeting) As a passenger in a car fr an hur withut a break Lying dwn t rest in the afternn when circumstances permit Sitting and talking with smene Sitting quietly after lunch withut alchl In a car, while stpped fr a few minutes in traffic... Scre

4 The Patient Health Questinnaire (PHQ-9) Patient Name Date Over the past 2 weeks, hw ften have yu been bthered by any f the fllwing prblems? Nt At All Several Days Mre Than Half The Days Nearly Every Day 1. Little interest r pleasure in ding things 2. Feeling dwn, depressed, r hpeless 3. Truble falling r staying asleep, r sleeping t much 4. Feeling tired r having little energy 5. Pr appetite r vereating 6. Feeling bad abut yurself r that yu are a failure r have let yurself r yur family dwn 7. Truble cncentrating n things, such as reading the newspaper r watching televisin 8. Mving r speaking s slwly that ther peple culd have nticed? Or the ppsite being s fidgety r restless that yu have been mving arund a lt mre than usual 9. Thughts that yu wuld be better ff dead r f hurting yurself in sme way Clumn Ttals: Add Ttals Tgether: 10. If yu checked ff any prblems, hw difficult have thse prblems made it fr yu t d yur wrk, take care f things at hme, r get alng with ther peple? Nt difficult at all Smewhat difficult Very difficult Extremely difficult Ref # 4173, Ver. 2

5 Patient Name SPOUSE/ROOMMATE QUESTIONNAIRE Date PLEASE HAVE SPOUSE/ROOMMATE COMPLETE. Check any f the fllwing behavirs yu have bserved the patient ding. WHILE ASLEEP WHILE AWAKE Lud snring Depressin Light snring Change in persnality Twitching f legs r feet Lss f intellectual functin Pauses in breathing Excessive daytime sleepiness Grinding teeth Weight gain Sleep walking Fatigue Bed wetting Mrning headache Sitting up in bed nt awake Irritability Kicking f the legs Getting ut f bed nt awake Sleep talking Hw lng have yu been aware f the sleep behavir that yu checked abve? Describe the sleep behavir described abve in mre detail. Include the type f activity, the time f night in which it ccurs, frequency during the night and whether it ccurs every night. If yu have described lud snring, d yu remember hearing shrt pauses in the snring r ccasinal lud snrts? Ref # 4179, Ver. 1

6 Abut Yur Billing Statements Why am I receiving tw separate billing statements? St. Charles Health System is an integrated healthcare delivery system that includes hspitals, utpatient services, and numerus clinic lcatins thrughut central Oregn. The St. Charles Sleep Center prvides physician services and utpatient testing facilities. The care yu receive at the Sleep Center will be billed n tw statements. St. Charles Medical Center will bill technical charges fr diagnstic testing. Statements frm St. Charles Medical Grup will include physician prfessinal charges and the facility charges fr clinic visits perfrmed at ne f ur utpatient clinics. What is a Facility Charge? Our physicians practice at a hspital utpatient facility t prvide the highest standard f care and quality t yu. If yu receive care at ne f ur lcatins, certain utpatient services and prcedures may result in a hspital facility charge as well as a prfessinal r physician charge. Depending n insurance cverage yur plan may apply different benefits t utpatient facility services, resulting in additinal deductible r c-payment amunts being due. We recmmend that yu review yur insurance benefits r cntact yur insurance prvider t determine what will be paid, and what, if any, ut-f-pcket expenses will be incurred. Patients with questins r cncerns regarding billing statements shuld call: St. Charles Medical Grup, Centralized Billing Office: (541) St. Charles Health System (St. Charles Medical Center), Patient Financial Services: (541) Ref #4170, Ver. 2

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