Reminder: We require 48 hours notice of any appointment change or cancellation. Date: Dear Mr./Mrs./Ms.
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- Evangeline Bond
- 6 years ago
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1 Date: Dear Mr./Mrs./Ms. Dr. has scheduled you for overnight sleep study on at 8:30 PM. You may park in the visitor parking lot at no charge. Be sure to bring your insurance information with you. While we check your insurance coverage we ask that you call your insurance company to verify your coverage. You will be responsible for any deductible and/or co-payment at the time of registration. On the night of your appointment, please bring all medications you are currently taking. A light snack if desired, sleepwear, toiletries, and any reading material you would prefer. To contact the lab directly in case of last minute questions call Our available procedure time is VERY limited. With our backlog of patients needing procedures, we believe it is not fair to other patients when a procedure time goes unused. Please try to give us at least 48 hours if you find it necessary to cancel or reschedule an appointment. This way we can fill the time with another patient who has been waiting for this important medical care. If canceling your appointment is necessary we ask that you notify us at least 48 hours in advance to avoid a $100 cancellation fee. If you have any questions concerning the testing procedure or how to complete the enclosed forms, please call the Sleep Referral Coordinator at and our staff will assist you. Cordially yours, Sleep Referral Coordinator Reminder: We require 48 hours notice of any appointment change or cancellation.
2 ENCLOSURE SLEEP LABORATORY PATIENT INSTRUCTIONS TO BE DONE ON THE DAY OF YOUR APPOINTMENT As natural body oils and normal dirt affect the functioning of the equipment used to perform this test, the following instructions must be carried out on the day of your scheduled appointment. FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN THE CANCELLATION OF YOUR TESTING: 1. COMPLETE SHOWER OR BATH: 2. WASH HAIR WITH SHAMPOO ONLY: Please no conditioners, hairdressing cream, oils, gels, or hairspray are to be used after your hair has been washed. 3. HAIR AND SCALP MUST BE COMPLETELY DRY: upon arrival at the sleep lab otherwise testing will be delayed. 4. FOR MEN: Please shave before coming in for your sleep study. This will help keep the sensors in place. If you have a beard please trim it is as much as possible before your study. 5. FOR WOMEN: If you wear makeup, please wash off before coming in for your sleep study. Do not wear nail polish on your pointer finger as it may interfere with pulse oximeter reading. ADDITIONAL INSTRUCTIONS INCLUDE: 6. FRESH NIGHT CLOTHES: Garments should be of a cotton or cotton-blend material. A loose fitting top such as a T-shirt or pajama with a button down front and loose fitting bottoms such as shorts, sweat pants, or pajama pants is recommended. Room temperature must be maintained between degrees for testing, bring nightclothes that will be comfortable for you under these conditions. You may bring reading material if you desire. Television is available but NOT during testing. 7. NO ALCOHOLIC OR CAFFEINATED BEVERAGES AND NO FOODS CONTAINING ALCOHOL OR CAFFEINE FOR AT LEAST 6 HOURS BEFORE TESTING: Alcohol and caffeine consumption will cause disruption of sleep cycles and therefore alter test results so please avoid foods and beverages that contain them on the day of your appointment. If you require a snack at night before bedtime please bring one with you, since we are an outpatient facility we do not have food service available. 8. PLEASE AVOID BRINGING VALUABLES TO THE FACILITY ON THE NIGHT OF YOUR SLEEP STUDY. 9. PLEASE BRING THE FOLLOWING ENCLOSED FORMS COMPLETED ON THE NIGHT OF YOUR STUDY: - Pre-test Questionnaire - Sleep Diary - Epworth Scale - Partner Questionnaire (if applicable) - Pediatric Questionnaire (if applicable) Reminder: We require 48 hours notice of any appointment change or cancellation.
3 What do I need to bring for the sleep study? An overnight bag. We recommend loose fitting clothing. For women: we recommend a two piece pajama set. Please note that we provide pillows and blankets at the sleep lab but you may bring the following items to make your stay more comfortable; favorite pillow/blanket reading material, teddy bear. Please take any medications before coming into lab. If you must take medication at night, please bring medications in their original containers. If you are an asthmatic, remember to bring your inhalers. Do I need to do anything differently the day of the test? Follow your normal routine and try to eat your meals as you normally eat and take your normal medications. We do ask that you avoid alcohol and caffeine at least 6 hours before the test. If you shave, shave your beard regularly, we also ask you shave before you arrive. Where do I go once I get to the sleep lab? Enter through the front entrance of the facility through the gates. Free parking is available beyond these gates. The lab is on the ground floor through the double doors. Please do not park next to the trash container. What if I can t sleep? We do not expect you to sleep just the same way that you do at home but our technicians work hard to create an environment that is as friendly and comfortable as possible. We need a minimum of two hours of sleep time to make a diagnosis but ideally six hours of sleep data is desired. What if I have a hair piece? If you have a hair piece it is important that you share this information with sleep referral coordinator at time of scheduling. If the technician cannot get to the scalp we won t be able to perform sleep study. Electrodes need to be placed on scalp in order for us to properly diagnose you. What time will I be awakened? The technologist will wake you between 5:30AM and 6:00AM. Who do I call if I have questions? Please call the Sleep Referral Who do I call if I arrive at the lab and find the doors locked? Please call Dimitri or Nausheen Who do I call for the results of my sleep study? Please wait at least two weeks before calling your doctor for the results of your sleep study. Reminder: We require 48 hours notice of any appointment change or cancellation.
4 By bus: Take X31, 61 or 79 Directions: By car from Brooklyn and Queens: Take the Belt Parkway or Brooklyn Queens Expressway to the Verrazano Bridge. Follow the Staten Island Expressway to the Richmond Avenue exit. Make a right onto Richmond Avenue. Make a left at Richmond Hill Road. Continue on Richmond Hill Road and Sleep Center is on the right hand side (center has a large red gate). By car from New Jersey via the Outer bridge Crossing: Take the Richmond Parkway to the end. Continue straight onto Richmond Avenue North. Proceed straight and make a right at the first traffic light onto Forest Hill Road. Make a left at the third light onto Richmond Hill Road - the Sleep Center is on the left hand side (center has a large red gate). By car from New Jersey via the Goethals Bridge: Take the Staten Island Expressway to the Richmond Avenue exit. Coming off the service road, make a left onto Lamberts Lane. Continue along Lamberts Lane to Richmond Avenue. At the first traffic light, make a right onto Richmond Avenue. Continue along Richmond Avenue to Richmond Hill Road. At the traffic light, make a left - approximately half a mile on the right. From Holland Tunnel: Take 14 th St/ I-78.New Jersey Turnpike Ext W Take Exit 14A toward Bayonne Take the E. 53 rd St ramp toward RT 440/Bayonne Bridge Turn Slight Right toward Rt-440 S. Turn Slight Right onto Pulaski St. Take Rt-440 S Take Exit 11 toward Victory BLVD Turn Slight Left onto Christopher LN Turn Right onto Victory BLVD Turn Left onto Richmond Ave Turn Richmond Hill Rd Lab will be on the Right Reminder: We require 48 hours notice of any appointment change or cancellation.
5 SLEEP STATISTICS More than 18 million Americans suffer from sleep apnea** It is conservatively estimated that 10 million Americans remain undiagnosed** More than half of all cases of sleep apnea are diagnosed in people 40 years of age or older** Sleep apnea is more prevalent in men than women** More than 70 million Americans suffer from disorders of sleep and wakefulness** Of the 70 million, nearly 60 percent have a chronic disorder** Research suggests that adults require an average of 8 to 8.5 hours of sleep each night** Each year, sleep disorders, sleep deprivation and sleepiness add an estimated $15.9 billion to the national health care bill** The International Classification of Sleep Disorders lists 84 sleep disorders of sleep and wakefulness that serve as a guide for diagnosis For a complete list of AASM-accredited sleep centers, visit org or call (888) 41-AWAKE **Statistic from the National Institutes of Health National Center for Sleep Disorder Research sleep apnea Sleep apnea is a common sleep disorder characterized by brief cessations in breathing during sleep. The two most frequent symptoms of sleep apnea are loud snoring and excessive daytime sleepiness; morning headaches and awakening with a dry mouth or sore throat are also signs of sleep apnea. In most cases, sleep apnea occurs when the throat muscles and tongue relax and partially block the opening of the airway during sleep. Though an individual continues their efforts to breathe, air cannot easily flow into or out of the nose and this results in heavy snoring, arousals, and periods of no breathing. There are two types of sleep apnea: central and obstructive. Central sleep apnea Central sleep apnea is characterized by a cessation or decrease in breathing during sleep. Individuals sustain several awakenings during the night, sometimes with a gasp for air. Additionally, individuals experience circulatory complications, including irregular heartbeats, pulmonary hypertension, and heart failure. Snoring may occur, though it is not prominent. Obstructive sleep apnea Obstructive sleep apnea, the more common of the two, is characterized by the muscles in the walls of the throat relaxing while the person sleeps so that the walls collapse on themselves and obstruct the flow of air. After about 30 seconds, the obstruction is relieved and breathing resumes. Symptoms of obstructive sleep apnea intensify with increased body weight and blood pressure. Individuals who believe they suffer from sleep apnea should first contact their primary care physician for a diagnosis. With the proper diagnosis, patients can begin testing and treatment, usually at a sleep center or lab. There are several treatment options available, and therapy is customized for the individual. Behavorial changes, including weight loss, changes in sleeping devices, and the avoidance of alcohol and sleeping pills, are suggested for mild cases. The most common treatment for more severe sleep apnea cases is continuous positive airway pressure (CPAP). The CPAP device is a mask that provides pressure from a blower that forces air and prevents airway closure. Dental devices are a less cumbersome alternative to CPAP, and are designed to move the jaw forward and subsequently open air passages. Additionally, surgical procedures that improve sleep apnea and snoring by enlarging air passages are options for individuals. The American Academy of Sleep Medicine is a professional organization dedicated to advancing sleep health care by setting clinical standards for the field; advocating for recognition, diagnosis and treatment of sleep disorders; educating professionals dedicated to providing optimal sleep health care; and fostering the development and application of scientific knowledge. AASM 2003 One Westbrook Corporate Center, Suite 920 Westchester, IL (708)
6 Night and Day Sleep Services Staten Island Fax to: Tel: SLEEP CENTER SLEEP DIARY Name: Appointment Date: & Time p.m. The purpose of this form is to provide us with your typical sleep habits. Please start filling it out daily, a week prior to your scheduled sleep study. If your study is less than a week away, give us as many days as you can. This will aid us in the diagnosis of your condition. Complete the top box each evening prior to bed, and complete the bottom box each morning when you get up. If there is an unusual event on a given night (e.g. illness, emergency, phone calls) make a note of it in the Unusual Events row. Are you a shift worker yes no If yes, what hours do you work? How many pillows do you usually sleep with? DATE Each nap time if any Total sleep during Each nap time Meds or alcohol taken as a Sleep aid at bed time (Y or N) Bedtime How long did it take you to Go to sleep? Rise time Total sleep during night Number of Night-time Awakenings Duration of each Awakening When I awake, I feel 1= exhausted 5=refreshed My sleep last night was: 1= very restless 5=refreshed Unsual Events Example 9/30 11am 3pm 15min 1 hr Y 11pm 1 hr 6am 5hrs 4 5, 15, and 25 mins 3 2 Phone call at 1am
7 Proper sleep hygiene has 4 components: I. Behavior II. Environment III. Diet IV. Exercise RULES OF SLEEP HYGIENE I. Behavior RULE 1: Have a regular schedule. Go to bed and wake-up at the same times, regardless of the day of the week. RULE 2: Have a relaxing pre-sleep routine. Engage in a routine prior to sleep in order to prep the mind/body for sleep. RULE 3: Ensure bedroom only used for sleep or intimacy. Only go to bed when drowsy. Do not eat, watch TV, or read in bed. RULE 4: Limit the time you spend awake in bed. If you are awake in bed for minutes, get up and leave bedroom. Engage in quiet activity until drowsy. RULE 5: Avoid naps. Only nap if necessary to retain alertness (30 minutes maximum). Avoid napping 6-8 hours prior to sleep. II. Environment RULE 6: Have a dark bedroom. Avoid bright lights, because bright lights can stimulate awake-sensors in eyes. RULE 7: Set cool temperature (or comfortable temperature). Uncomfortably warm bedrooms disrupt sleep. RULE 8: Avoid/minimize loud noises. Use ear plugs or white noise machines to minimize loud noises. RULE 9: Have a bedroom free of potential allergens. Allergens can disrupt sleep because of sneezing, sniffing, and coughing. III. Diet RULE 10: RULE 11: RULE 12: RULE 13: Avoid caffeine 6-8 hours before sleep. Chocolate, some teas, coffee contain caffeine. Reasonable daily amount of caffeine is 1-2 cups of coffee. Avoid alcohol 3-5 hours before sleep. Alcohol may help sleep onset, but sleep will be fragmented and poor quality. Avoid nicotine prior to sleep. Withdrawal symptoms can disrupt sleep. Eat a light carbohydrate snack prior to sleep. Hunger can disrupt sleep. Avoid large meals prior to sleep. Avoid sugars and caffeine. IV. Exercise RULE 14: Exercise regularly. Regular exercise promotes a regular sleep/wake schedule. The body likes a routine. RULE 15: Avoid strenuous exercise 3-5 hours before sleep. Exercise raises body temperature. During sleep body temperature lowers, and increased body temperature confuses the mind/body of the regular sleep/wake schedule.
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9 MR No. Patient Account: PRE-TEST QUESTIONNAIRE These questions are necessary for the physician to evaluate your test and must be filled out prior to your appointment. If you are not sure how to answer a question it can be discussed with the technician at the time of your test. Do not alter your normal routine or make any adjustments in medications that you have been using for sedation, sleep or to maintain wakefulness. Please do not consume alcohol or caffeine on the day of your test. NAME: DOB: ADDRESS: PHONE Emergency Contact PHONE Referring MD PHONE Reason for Study SEX HEIGHT Feet. Inches WEIGHT lbs NECK SIZE Inches What was your weight: 6 months ago 2 years ago At age 20 What was your heaviest weight MEDICAL CONDITIONS (check if present) High Blood Pressure Heart Disease Heart Attack Congestive Heart Failure Kidney Disease Asthma Emphysema Bronchitis Diabetes Thyroid Dysfunction Seizures Stomach Problems Chronic Headaches Depression COPD Obesity (Mild/Moderate/Severe) Ear, Nose, Sinus or Throat Problems Deviated Septum Claustrophobic Other MEDICATIONS: Frequency: Dosage: Use back of page for additional meds. ALLERGIES Have you ever had a Sleep Study done? YES NO If YES, where and when was it performed? Page 1 of 4
10 Sleep Center Pre-Test Questionnaire NAME DATE 1. Do you feel you get too little sleep at night? YES NO 2. Do you feel that you get too much sleep? YES NO 3. What time do you normally go to bed? a. How long are you in bed before you decide to go to sleep? Hours Minutes 4. Do you have difficulty falling to sleep? YES NO a. How long does it usually take to fall asleep? Hours Minutes 5. Do you wake up during the night? YES NO a. How often do you wake up on an average night? Number of times 6. What time do you normally wake up in the morning? a. How do you normally wake up? Spontaneously Alarm Clock Other 7. Do you usually wake up before you need to? YES NO a. If yes, how much earlier do you wake up than is necessary? Hours Minutes 8. Do you feel well rested after you sleep? YES NO a. How difficult is it for you to awaken and get out of bed after sleeping? Very difficult Difficult Sometimes Difficult No Problem 9. Do you usually feel fatigued during the daytime? YES NO a. If YES, how often? Rarely Occasionally Frequently b. Do you find yourself falling asleep when you don t want to? YES NO c. Does fatigue make it difficult to do your daily activities? YES NO d. Do you experience drowsiness while driving? YES NO e. If yes, is it during: short distance driving long distance driving 10. Do you take naps during the day if your situation permits? YES NO a. If yes, how many times during the day do you nap? b. On the average, how long do your naps last? Hours Minutes c. Do you feel rested after you take a nap? YES NO 11. Do you have a regular bed partner? YES NO 12. Are you aware of, or have you been told that you Snore while you are asleep? YES NO a. If yes, how long has this occurred? Years Months b. Is it worse when you sleep on your: Back Side Stomach c. Does your snoring ever wake YOU up? YES NO d. Does it disturb someone in another room? YES NO Page 2 of 4
11 Sleep Center Pre-Test Questionnaire NAME DATE 13. Are you aware of or have you been told that you: a. Stop breathing or breathe irregularly in sleep? YES NO b. Are you a restless sleeper, tossing, turning often? YES NO c. Have arm or leg movements during sleep? YES NO d. Wake up gasping, choking or short of breath? YES NO e. Wake up with palpitations or irregular pulse YES NO f. Talk in your sleep? YES NO g. Grind your teeth in your sleep? YES NO h. Wake up with indigestion or acid stomach? YES NO i. Wake up feeling confused? YES NO 14. Do you have sleep irregularities related to your work? YES NO a. Do you work nights/evenings? YES NO b. Do you rotate shifts? YES NO 15. Do you experience headaches? YES NO a. If yes, how often do they occur? Rarely Occassionally Frequent b. Do they occur in the morning when you wake up? YES NO c. Do they wake you up from sleep? YES NO 16. Do you ever experience arm or leg sensations prior to falling asleep or when you wake up? a. Pain or cramping? YES NO b. Restless sensation? YES NO c. Crawling sensation? YES NO d. Twitching or jerking? YES NO e. If yes, does it cause you difficulty in falling asleep? YES NO f. Does it wake you up during the night? YES NO g. Does anything relieve the sensation (i.e. getting out of bed, walking, massage, medication)? h. How many times a week does this occur? 17. What positions do you tend to sleep in? On right side On left side On back On stomach 18. How many pillows do you sleep with? More 19. Do you use any breathing aid for sleep? YES NO a. Do you use a CPAP or BIPAP breathing machine when you sleep? YES NO b.. If yes, what is the setting? c. Do you use oxygen at home? YES NO d. If yes, what is the setting? Page 3 of 4
12 Sleep Center Pre-Test Questionnaire NAME DATE 20. Have you ever used any medications, prescription or non-prescriptions to: a. Help you sleep? YES NO b. Help you stay awake during the day? YES NO 21. Does anyone in your family have any sleep related problems? YES NO a. If yes, how are they related to you? b. What is their problem? 22. Do you have any problems with: a. Nasal Congestion YES NO b. Nasal Obstruction YES NO c. Nasal discharge YES NO d. Nasal Polyps YES NO e. Sinuses YES NO f. Tonsils YES NO g. Adenoids YES NO h. Difficulty Swallowing YES NO i. Lump or obstruction in your throat YES NO j. Change in your voice within the last year YES NO k. Thyroid Condition YES NO 23. Have you ever had any of the following surgeries: a. Tonsillectomy YES NO b. Adenoidectomy YES NO c. Nasal Surgery YES NO d. Sinus Surgery YES NO e. Vocal Cord Surgery YES NO 24. Do you consume alcohol? YES NO a. If yes, how often? Occasionally/Socially Weekends More Often b. On an average, how many alcoholic beverages consumed per week? 25. Do you smoke? Yes No a. Cigarettes packs per day b. Cigars per day c. Pipe per day 26. Do you consume caffeine? Yes No Servings per day PSG Study Date: / / PSG Sleep Clinician PSG Study scored by Date: / / Reviewed by MD Interp. Split/CPAP/PAP NAP Study Date: / / Split/Titration Sleep Clinician: Split/Titration Study Scored by Date: / / Reviewed Split/Titration MD Interp. Page 4 of 4
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14 Night and Day Sleep Services Staten Island Fax to: SLEEP CENTER PARTNER QUESTIONAIRE Patient name: Today s Date: QUESTIONAIRE Please check the appropriate box regarding your relationship to the patient SPOUSE PARTNER ROOMMATE PARENT Please check which of the following behaviors you have observed the patient doing while asleep Loud Snoring Light Snoring Flailing of arms and legs Twitching of legs and feet Breathing pauses (10 sec or more) Grinding teeth Sleep talking Sleepwalking Bed Wetting Sitting up in bed while asleep Rocking or banging of head Getting out of bed while asleep Tongue biting Becoming very rigid and/or shaking How long have you been aware of these sleep behaviors? Please describe in further detail these observed sleep behaviors:
15 SLEEP CENTER EPWORTH SLEEPINESS SCALE Name: Appointment Date: & Time p.m. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent activities. Even if you have not done some of these things recently try to work out how they would have affected you. 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 **PATIENT** (please complete) SITUATION 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
Dr. has scheduled you for overnight sleep study on at 8:30 PM. You may park in the visitor parking lot at no charge.
Night and Day Sleep Services Staten Island Fax to: 914-333-5925 www.nightanddaysleep.com Tel: 914-333-5813 Date: Dear Mr./Mrs./Ms. Dr. has scheduled you for overnight sleep study on at 8:30 PM. You may
BRING THEM WITH YOU ON THE NIGHT OF YOUR APPOINTMENT.
1211 Hamburg Turnpike, Suite 207, Wayne, NJ 07470 Attn: Sleep Referral Coordinator Date: Dear Mr./Mrs./Ms. Dr. has scheduled you for overnight sleep study on at 9:00 PM. The sleep center is located on
Dr. Wakefield has scheduled you for overnight sleep study on at 8:30 PM. You may park in the visitor parking lot at no charge.
901 Stewart Avenue, Suite 270, Garden City, NY 11530 Attn: Sleep Referral Coordinator Date: Dear Mr./Ms./Mrs. Dr. Wakefield has scheduled you for overnight sleep study on at 8:30 PM. You may park in the
Dr. has scheduled you for an overnight sleep study on at 8:45 PM. You may park in the visitor parking lot at no charge.
350 Engle Street, Englewood, NJ 07631 Date: Dear Mr./Ms./Mrs. Dr. has scheduled you for an overnight sleep study on at 8:45 PM. You may park in the visitor parking lot at no charge. Be sure to bring a
Night and Day Sleep Services Phelps Memorial Hospital Sleep Disorders Diagnostic Center
Night and Day Sleep Services Phelps Memorial Hospital Sleep Disorders Diagnostic Center 701 North Broadway, Sleepy Hollow, NY 10591 www.nightanddaysleep.com Date: Dear Dr. has scheduled you for overnight
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)
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Denver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
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:
SLEEP HISTORY QUESTIONNAIRE
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Robert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study
NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A 811 West Interstate 20, Suite G12 Arlington, Texas 76017 (817) 419-6375 Fax (817) 419-6371 Robert E. McMichael, M.D. Medical Director
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SLEEP DISORDERS CENTER St. Joseph Mercy Ann Arbor 5305 Elliott Drive, Ypsilanti, MI 48197 734-712-2276 / Fax 734-712-2967 Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness
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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:
Sleep Study Information
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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.
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.
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.
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. Dear, Your physician has requested that you be scheduled for a sleep study. Your appointment
Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
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
Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
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
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
Patient History & Sleep Questionnaire
Patient History & Sleep Questionnaire Patient Full Name: Nick Name: Birth date: Age: Sex: Height: Current Weight: Weight Five Years Ago: Peak Lifetime Weight: Marital Status: Single Married Divorced Widowed
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
*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 Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
Sleep Center of Willmar LLC
Sleep Center of Willmar LLC 1801 19 th Avenue South West Willmar, MN. 56201 320-441-2104 (telephone) 320-441-2052 (facsimile) Welcome Our staff understands that quality care and patient comfort go hand
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
Section of Pediatric Sleep Medicine
Section of Pediatric Sleep Medicine David Gozal, MD Hari Bandla, MD Date: Dear Parent or Caregiver; Thank you for your interest in the Sleep Disorders Program. The sleep clinic s standard assessment procedure
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
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).
Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
I would like for my patient to be seen in Sleep Medicine consultation and managed by the sleep physician. Yes No
701 E. COUNTY LINE ROAD, SUITE 207. GREENWOOD, IN. 46143 OFFICE317-887-6400 FAX 317-887-6500 indianasleepcenter.com REFERRAL FOR SLEEP EVALUATION Patient Name:_ Phone: I would like for my patient to be
General Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
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
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
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
Your appointment is scheduled for at with Dr. Dimitri Markov.
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) 215-503-3300
Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
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 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
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
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE Please answer each question accurately and to the best of your knowledge, to help us obtain an accurate picture of your health and sleep issues, only this way will we be able
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
Sleep Medicine Associates
Date: Patient Name: DOB: Patient Height: _ Weight: _ lbs Referring Physician: Neck Size: Main Sleep Problems: 1. My main sleep complaint is: Trouble Sleeping at night Sleepy during the day Unusual behavior
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
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
Sleep Questionnaire. Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago:
Sleep Questionnaire Patient's Name: Referring Dr.: Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago: Weight 5 years ago: 5 yrs ago: 10
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
Sleep Medicine Questionnaire
Please bring this completed questionnaire with you to your sleep medicine appointment. Our sleep medicine staff strives to understand your sleep symptoms, which may be complex in nature. Thank you for
***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
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
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
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
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
SLEEP STUDY - PATIENT QUESTIONNAIRE
NOTE: You cannot fill out this form on Mozilla Firefox, please try another browser. You have two options for completing a questionnaire: - Enter the information on the fillable PDF and click Print at the
Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. For how many months/years?
St. Louis Heart and Vascular - McKelvey Office May 28, 2018 (Page 1) Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. Today s Date: My Main
Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
IMPORTANT INFORMATION
Joint Commission Accredited to Perform Medicare, NV Medicaid, HPN Medicaid and Tricare Military Sleep Studies You have been scheduled for an overnight sleep study at our facility. The following important
THE PERMANENTE MEDICAL GROUP
Patient label here THE PERMANENTE MEDICAL GROUP Division of Sleep Medicine COMPLETED BY: PARENT/GUARDIAN CHILD/ADOLESCENT Age: Height: Weight: PEDIATRIC SLEEP QUESTIONNAIRE Thank you completing this questionnaire.
PEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
Sleep Center New Patient Questionnaire
For office use only Appt date: Sleep Center Clinician: Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 #1 respiratory hospital
Melatonin replacement and sleep program
Melatonin replacement and sleep program This questionnaire will take approximately 10 minutes to complete. The information you provide is very important and will assist our sleep specialists during the
993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD
993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD Atlanta, Georgia 30342 David E Westerman, MD 404-303-1700/ Fax: 404-252-9527 Alex Hebert, NP-C To our New Sleep Patient: On behalf of North Atlanta
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
SLEEP DISORDERS CENTER QUESTIONNAIRE
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
BMI: Family physician : Neck circumference (cm) Hypertension + 4 cm Snoring + 3 cm Witnessed apnea + 3cm Total
Last and first names: F M Date: Date of birth: / / YYYY MM DD Weight: kg /lbs Profession/job: Height: _ cm /ft.in. BMI:_ Family physician : ANC (adjusted neck circumference) : Neck circumference (cm) Hypertension
HEALTHY LIFESTYLE, HEALTHY SLEEP. There are many different sleep disorders, and almost all of them can be improved with lifestyle changes.
HEALTHY LIFESTYLE, HEALTHY SLEEP There are many different sleep disorders, and almost all of them can be improved with lifestyle changes. HEALTHY LIFESTYLE, HEALTHY SLEEP There are many different sleep
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
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA 70301 985-493-4759 SLEEP HISTORY QUESTIONNAIRE DATE: / / NAME: AGE (First) (Middle) (Last) ADDRESS: (Street) (City) (State) (Zip) PHONE: Home( ) Work:( )
Frequently Asked Questions
Q- What is Sleep Apnea? Frequently Asked Questions A- Sleep Apnea, sometimes known as the "silent killer" although there is usually nothing silent about it. It is associated with periodic loud snoring
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
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
The Polyclinic Sleep Center
We look forward to seeing you at 7:30 p.m. on for your sleep study appointment. If you anticipate being late or are unable to keep your scheduled appointment, please call Dr. Chang s office between the
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:
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
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
Height: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other
Personal Information Name: Date of birth: Sex: Male Female Marital Status: Nationality: MRN(for KAUH Patients): Height: Weight: Neck Size: Address: Occupation: Length of work day: Does your work involve
Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
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/
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
Please note: we have several facilities in Oregon, be sure you understand clearly which Sleep Center you are scheduled for:
Providence Sleep Disorders Centers Dear Sleep Study Patient: Thank-you for choosing Providence for your Sleep Study. Please note: we have several facilities in Oregon, be sure you understand clearly which
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
SLEEP DISORDERS INVENTORY
1090 Amsterdam, 17th Floor New York, New York 10025 212-994-5100 Toll Free: 888-SLEEP-NY Fax: 212-994-5101 SLEEP DISORDERS INVENTORY Gary K. Zammit, Ph.D., Stephen Lund, M.D., Joseph Ghassibi, M.D., Kathleen
SLEEP STUDY. Nighttime. 1. How many hours of sleep are you now getting in a typical night?
SLEEP STUDY Patient Name: Date of Birth: Date of Study: This questionnaire involves a broad range of sleep and sleep-related behaviors. Your answers enable us to develop a clearer picture of your sleep/wake
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
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
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
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)
Welcome to the UCLA Sleep Disorders Center Our Sleep Center Website is:
Sleep Disorders Center 10833 Le Conte Avenue, B Level Los Angeles, CA 90095 1-310-26SLEEP (7-5337) Welcome to the UCLA Sleep Disorders Center Our Sleep Center Website is: http://sleepcenter.ucla.edu Sleep
Sleep History Questionnaire
Location South Loop Katy Steeplechase Fort Bend NAME ADDRESS PHONE SEX DOB AGE HEIGHT WEIGHT NECK COLLAR SIZE (inches) Do you have difficulty falling asleep? Is your sleep restless or disturbed? Do you
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
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
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