INTAKE FORM AND SLEEP QUESTIONNAIRE

Transcription

1 INTAKE FORM AND SLEEP QUESTIONNAIRE Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD Name: Date f Birth: Date: Address: Primary Phne: ( ) Secndary Phne: ( ) Insurance Cmpany: D yu have insurance thrugh the Affrdable Care Act (cmmnly called Obama Care)? Yes N Hw did yu find ut abut us? My dctr [ ] My friend [ ] My family [ ] My insurance [ ] Yur website [ ] Advertisement Referring Physician: Primary Care Physician: What is yur height? Feet Inches Gender: Male Female What is yur weight tday? Weight ne year ag? Weight five years ag? My Main Sleep Cmplaint (please explain): Reasn yur dctr sent yu t ur ffice (please explain): Please check all f the fllwing statements that are true abut yur sleep: Breathing Prblems: Duratin f Symptms: mnths / years I have been tld that I snre I wake up at night chking, smthering r gasping fr air I have been awakened by my wn snring I have been tld I stp breathing during sleep I sweat a great deal at night My snring / breathing is wrse if I fall asleep after alchl My snring / breathing is wrse if I sleep n my back My heart punds / beats rapidly r beats irregularly at night Daytime Sleepiness: Duratin f Symptms: mnths / years I take daytime naps I fall asleep while watching TV I fall asleep in sedentary situatins I perfrmed prly at wrk due t sleepiness I perfrmed prly at schl due t sleepiness I am sleepy during the day, struggling t stay awake I have fallen asleep while driving I have fallen asleep during cnversatins I have had aut accidents due t falling asleep while driving I have had injuries as the result f sleepiness I have had blackuts r perids when I am unable t remember what just happened I have slept fr several days at a time, r at least I have been verwhelmingly sleepy fr that lng I see dream-like images (hallucinatins) either just befre, just after a daytime nap r as I wake up in the mrning, even thugh I am nt asleep I have had the inability t mve (paralyzed) while falling asleep r when waking up I get sudden muscular weakness when laughing, angry r in situatins f strng emtins I need smething t help me stay awake during the day, I use Page1 Past Sleep Evaluatin and/r Treatment: Duratin f Symptms: mnths / years I have had a previus sleep disrder evaluatin I have been prescribed PAP fr hme use I wear xygen at night I have had a previus vernight sleep study I have had surgical treatment fr a sleep disrder I have a family member with sleep apnea Please list 1) Date f Prir Sleep Study 2) Diagnsis 3) Treatment 4) Sleep Lab Name: Patient Name DOB:

2 Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD Restlessness Prblems: Duratin f Symptms: mnths / years I am a restless sleeper I have a difficult time falling back t sleep after I awaken I wake up ften during the night I typically wake up frm sleep t g t the restrm I have talked in my sleep as an adult I have been tld that I kick/jerk my legs/arms during sleep I have walked in my sleep as an adult I smetimes act ut my dreams I grind my teeth in my sleep I have injured myself r anther while acting ut a dream I have a strng urge t mve my legs (restless leg symptms) which I ntice in the evenings, especially when I m sitting in the evening r lying dwn t in bed (example: activities that bther me at night d nt bther me during the day.) I have an unusual feeling my legs and I m unable t resist mving them (the need t mve is ften accmpanied by hard-t describe sensatins. Sme wrds used t describe these include: creeping, itching, pulling, creepy-crawly, tugging r gnawing. ) These symptms start r becme wrse when I am resting (example: the lnger I rest, the greater the chance the symptms will ccur and the mre severe they are likely t be; it can ccur as a passenger in a car, n an airplane, in a mvie theatre, etc.) These symptms get better when I mve (example: the relief is cmplete r partial but generally starts very sn after starting an activity. Relief persists as lng as the mtr activity cntinues.) Other Sleep Prblems: Duratin f Symptms: mnths / years I have truble falling asleep / insmnia I have been unable t sleep at all fr several days My sleep is disturbed by sadness r depressin I have cnsidered r attempted suicide I have a decreased desire / interest in sex I am unhappy abut lving relatinships in my life I have a lt f nightmares (frightening dreams) A family member has been hspitalized fr a psychiatric illness I have racing thughts when I try t fall asleep I use alchl t cpe with stress I have difficulty returning t sleep if I wake up during the night I wake up early in the mrning, despite being tired, I am unable t return t sleep I need smething t help me get t sleep and/r stay asleep. I use _ Sleep Habits: I usually watch TV in bed prir t sleep I usually read in bed prir t sleep I eat a snack at bedtime I wrk a rtating shift r I am a shift wrker Bedrm Habits: I sleep alne I share a bed with smene I share a dwelling but have separate bedrms I share the bed with pets I smke prir t bedtime r when I awaken during the night I eat if I wake up during the night I ften travel acrss tw (2) r mre time znes I drink alchl in the evening time t help get t / stay asleep I have an uncmfrtable bed r pillw I have an uncmfrtable temperature in the bedrm I have a nisy bedrm r have t much light in the bedrm I have t many electrical devices in the bedrm Page2 Sleep Pattern: Typical bedtime AM/PM Hw many minutes t fall asleep _ Hw many awakenings in the night? _ D yu fall back t sleep easily? YES / NO Typical wake-up time AM/PM D yu nap? YES / NO If yes, when / hw lng Patient Name DOB:

3 Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD Epwrth Sleepiness Scale Use the fllwing scale t chse the mst apprpriate number fr each situatin: 0 = wuld never dze r sleep. 2 = mderate chance f dzing r sleeping 1 = slight chance f dzing r sleeping 3 = high chance f dzing r sleeping Situatin Chance f Dzing r Sleeping Sitting and reading Watching TV Sitting inactive in a public place Being a passenger in a mtr vehicle fr an hur r mre Lying dwn in the afternn Sitting and talking t smene Stpped fr a few minutes in traffic while driving Sitting quietly after lunch (n alchl) TOTAL (This is yur Epwrth Sleepiness scre) Past Medical Histry: Hypertensin (high bld pressure) Heart Disease Strke TIA "Light Strke" Diabetes Cancer Lung prblems/copd/asthma Reflux Stmach r cln prblems Thyrid prblems Hepatitis/jaundice Back r jint prblems (arthritis) Hearing impairment Fibrmyalgia Blackuts Seizures Depressin Anxiety Alchlism Chemical dependency r abuse Female Premenstrual syndrme Menpause Male Prstate prblems Erectile dysfunctin/imptence List ther past medical prblems and dates: Past Surgeries: Page3 Patient Name DOB:

4 Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD Current Medicatins: Medicatin Dse #per day Medicatin Dse #per day MEDICATION ALLERGIES: Family Histry: Has an immediate bld relative (Father/Mther/Sister/Brther/Child) had any f the fllwing? Relatin Relatin Cancer Strke Diabetes Anxiety/Depressin Hypertensin Sleep Apnea Heart disease Narclepsy Thyrid disease Other: Scial Histry: Marital Status: Number f Children: Emplyment status (circle all that apply): Emplyed Unemplyed Retired Student Occupatin: My wrk hurs are: My jb requires a DOT license: YES NO DOT anniversary: Have yu ever smked? YES NO If yes, hw lng have yu smked? Years Hw much? Packs per day Have yu quit smking? YES NO Year Quit D yu drink alchl? YES NO If yes, hw much d yu feel yu drink? Drinks Hw frequent? DAILY WEEKLY ( times per week) SOCIALLY What kind f alchl? BEER LIQUOR WINE Page4 D yu drink caffeine? YES NO Amunt: Check any f the fllwing symptms yu have had in the past 12 mnths: Frequent headaches Frequent heartburn / indigestin Mrning headaches Difficulty swallwing r fd "sticking" Fainting r passing ut Abdminal pain Sudden lss f visin r strength Frequent cnstipatin Inability t speak Frequent diarrhea Hearing lss r ringing in ear(s) Rectal bleeding / black stls Harseness fr mre than 2-4 weeks Difficulty urinating / incntinence Nsebleeds Bld in urine Cugh fr mre than 2-4 weeks Urinating mre than 2 times per night Cughing up bld Pain in jints r bnes Shrtness f breath r wheezing Unusual bruising r bleeding Swelling in feet r ankles Epilepsy / seizures Chest pain, tightness r pressure Change in wart, mle r skin grwth Irregular r sudden, fast heartbeat Weight lss f mre than 5-10 lbs. Patient Name DOB:

5 Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD BED PARTNER QUESTIONNAIRE Patient s name: Date f Birth: Date: If yu have a bed partner (r smene wh bserves yu while sleeping), please have them cmplete this questinnaire. Check any f the fllwing behavirs that yu have bserved the patient ding while asleep: Lud snring Bedwetting Light snring Sitting up in bed while still asleep Pauses in breathing Head rcking r banging Grinding teeth Kicking r twitching f legs r feet Sleep talking Getting ut f bed while still asleep Sleepwalking Biting tngue Acting ut f dreams Becming very rigid and/r shaking Hw lng have yu been aware f the sleep behavir(s) that yu checked abve? Describe the behavir(s) checked abve in mre detail. Include a descriptin f the activity, the time during the night when it ccurs, hw many times during the night and whether it ccurs every night. If yu have heard lud snring, describe it in mre detail. Include descriptins f any pauses in breathing r ccasinal lud snrts that yu may have nticed. OFFICE USE ONLY (Cnsult) Weight: Height: Saturatin: Pulse: BP: _ /_ Page5 Patient Name DOB:

6 HIPAA ACKNOWLEDGEMENT AND CONSENT FORM REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C. Patient Name: DOB: (Patient initials) Ntice f Privacy Practices. I acknwledge that I have had the pprtunity t receive the practice s Ntice f Privacy Practices, which describes the way in which the practice may use and disclse my healthcare infrmatin fr its treatment, payment, healthcare peratins and ther described and permitted uses and disclsures. I understand that I may cntact the Privacy Office designated n the ntice if I have questin r cmplaint. T the extent permitted by law, I cnsent t the use and disclsure f my infrmatin fr the purpses described in the practice s Ntice f Privacy Practices. (Patient initials) Release f Infrmatin. I hereby permit practice and the physician(s) r ther health prfessinals invlved in the utpatient care t release healthcare infrmatin fr purpses f treatment, payment, durable medical equipment r healthcare peratins. Healthcare infrmatin regarding prir treatment at ther healthcare facilities may be made available fr subsequent treatment t crdinate patient care r fr case management purpses. Healthcare infrmatin may be released t any persn r entity liable fr payment n the patient s behalf in rder t verify cverage r payment questins, r fr any ther purpse related t benefit payment. Healthcare infrmatin may als be released t my emplyer s designee when the services delivered are related t a claim under wrker s cmpensatin. If I am cvered by Medicare r Medicaid, I authrize the release f healthcare infrmatin t the Scial Security Administratin r its intermediaries r carriers fr payment f a Medicare claim r t the apprpriate state agency fr payment f a Medicaid claim. The infrmatin may include, withut limitatin, histry and physical, labratry reprts, perative reprts, physician prgress ntes, clinical ntes, cnsultatins, psychlgical and/r psychiatric reprts, drug and alchl treatment, infectius diseases including but nt limited t bld brne diseases such as HIV / AIDS and release f care summary. (Patient initials) Disclsures t Family Members and/r Friends. I give permissin fr my Prtected Health Infrmatin t be disclsed fr purpses f cmmunicating results, finding s and care decisins t the family members and thers listed belw: Name Relatinship Cntact Number (Patient initials) Cnsent t r Text Appintment Reminders and Other Healthcare Cmmunicatins. Patients in ur practice may be cntacted via and/r text message t remind yu f an appintment, t btain feedback n yur experience with ur healthcare team and t prvide general health reminders/infrmatin. If at any time I prvide an r text address at which I may be cntacted, I cnsent t receiving appintment reminders and ther healthcare cmmunicatins/infrmatin at that address frm the Practice. I understand at any time I can request a change in writing fr revcatin f this cnsent. Please be advised, ur practice des nt charge fr this service, but standard text messaging rates may apply as prvided in yur wireless plan (cntact yur carrier fr pricing plans and details). Address: Text Message: ( ) (Patient initials) Cnsent fr Prescriptin Order Pick-up. In the event ur ffice wuld be asked t release a prescriptin t a family member r friend, we will need t have a recrd f their name. Prir t release f the script, yur designee will need t present valid picture identificatin and sign fr the prescriptin. If yu wish t authrize a designate t pick-up prescriptins n yur behalf, please list belw: Name Relatinship Cntact Number This authrizatin is effective fr the duratin f my treatment with REMedy Sleep Medicine, L.L.C. unless revked r terminated by the patient r the persnal representative. It is understd that my recrds may nt be released t me at the same time as requested. The patient must allw 24 hurs t 30 days frm the time f their initial request. This authrizatin may be revked r terminated at any time by REMedy Sleep Medicine, L.L.C. r the patient. Revcatin will nt apply t infrmatin that has already been released in respnse t this authrizatin. Infrmatin that is disclsed under this authrizatin may be disclsed again by the persn r rganizatin t which it was sent. The privacy f this infrmatin is in cmpliance with the Health Insurance Privacy and Accuntability Act f 1996 (HIPAA). Patient Signature / Authrized Representative Relatinship t Patient Date Witness Signature Date

7 Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD INFORMATION REQUEST Patient Authrizatin All sectins f this authrizatin frm must be cmpleted t be valid in accrdance with 42 CFR Parts 160 and 164 Patient Name: Date f Birth: Address: City: State: Zip: Address: Phne: I request my prtected health infrmatin (PHI) frm: I request my prtected health infrmatin (PHI) be released t: REMedy Sleep Medicine, LLC 8625 Cllege Bulevard, Suite 103 Overland Park, Kansas P: (913) F: (913) I authrize the fllwing PHI t be released frm my medical recrds: Cmplete Medical Recrd (all pages) Sleep Study Reprt(s) Labratry & DME Reprt(s) Cvering the perid f health care frm: All past, present and future encunters / visits Purpse fr requesting infrmatin: Cntinuatin f Care Hw infrmatin is t be received: US Mail paper frmat (t patient) By signing this authrizatin frm, I understand that: Fax t healthcare prvider nly Requests fr cpies f medical recrds and/r nn-dcument material may be subject t cpying fees. PHI may include recrds relating t mental health care, cmmunicable diseases, HIV / AIDS and/r treatment f alchl/drug abuse. I have the right t revke this authrizatin at any time. Revcatin must be made in writing and presented t the Office Administratin. Unless therwise revked, this authrizatin will expire n the fllwing date / event / cnditin:. Revcatin will nt apply t infrmatin that has already been released in respnse t this authrizatin. If I fail t specify any expiratin date / event / cnditin, this authrizatin will expire ne year frm the date signed. Treatment, payment, enrllment r eligibility fr benefits may nt be cnditined n whether I sign this authrizatin. Any disclsure f infrmatin carries with it the ptential fr unauthrized re-disclsure and the infrmatin may nt be prtected by federal cnfidentiality rules. Patient Authrized Representative Signature: Date: Printed Name f Authrized Representative: Relatinship: Witness Signature: Date: Time: *If signed by a patient s authrized representative, supprting legal dcumentatin MUST accmpany this authrizatin frm*

8 Phne: (913) Carle Guillaume, MD, FAASM Leah Luckerth, MD AUTHORIZATION FOR TREATMENT AND SERVICES, ASSIGNMENT OF BENEFITS AND CHARGE TO MY CREDIT CARD Patient Name: DOB: Authrizatin fr Treatment and Services. I hereby authrize and accept medical treatment fr myself and fr my dependents as deemed necessary by REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C. I als authrize REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D. and its fficers, directrs and its designated emplyees and agents, t furnish infrmatin t insurance cmpanies and ther medical prfessinals regarding treatment(s) and services prvided t me and t my dependents, and regarding my medical cnditin(s) and thse f my dependent(s). I hereby assign t REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., and t its physician emplyees, all payments made fr medical treatments and services prvided t me r t my dependent(s). I understand and agree that I am primarily respnsible fr the payment f all charges rendered by REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., and by its physician emplyees, Leah Luckerth, M.D., fr such medical treatment and services whether r nt such charges are cvered (either fully / partially) and paid (either fully / partially) by insurance. CREDIT CARD POLICY I fully understand the plicy f REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C. which is t secure an imprint f my credit card at the time f my initial ffice visit. If, after a claim has been submitted t my insurance carrier(s), either (1) the claim is denied fr any reasn, r (2) the charges are either nt paid, r nly partially paid, by my insurance carrier(s), then in any f such events, REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., will charge my credit card fr the amunt(s) then wing fr medical treatment(s) and service(s) prvided t me. I understand that in the event that my credit card has been charged fr medical treatment(s) and service(s) prvided t me, and my insurance carrier(s) subsequently makes payment t Carle Guillaume, M.D. r Leah Luckerth, M.D. f all r a part f such charges, that Carle Guillaume, M.D. will issue a credit in such amunt received frm my insurance carrier(s) t my credit card. Credit Card Type Ο Visa Ο Master Card Ο Discver Ο American Express Ο H.S.A. Last 4-Digits f Credit Card Number: XXXX-XXXX-XXXX-_ Expiratin Date: / _ CV2: Name f Card Hlder: Address: Telephne Number: ( )_ I hereby authrize and direct REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., a Kansas-based Limited Liability Cmpany, and its designated agents and emplyees t prcess and charge my credit card (specified abve) the full amunt f all charges made fr medical treatments and services prvided by REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., and understand that the amunt charged t my credit card will be reflected n my credit card statement. The amunt charged will be based n the medical treatment(s) and service(s) rendered t me r my dependents as requested by me and the usual and custmary charges made by REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., fr such treatment(s) and service(s). Ntwithstanding the abve, I hereby guarantee payment f all charges fr medical treatments and services prvided t me r t my dependent(s) by REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., and agree that if REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., places my accunt in the hands f a cllectin agency r an attrney fr enfrcement r cllectin, in either such events, REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C., shall have the right t be paid back by me fr all f its csts and expenses in cllecting mnies wed t them by me fr medical treatment(s) and service(s) prvided t me t the extent nt prhibited by applicable law. Thse expenses include, fr example, but shall nt be limited t, reasnable attrneys fees, curt csts and ther expenses incurred in cnnectin with cllectin f my accunt by a cllectin agency r an attrney. This authrizatin shall be and remain effective unless and until expressly revked by me in writing delivered t the ffice f REMedy Sleep Medicine, L.L.C. / Carle Guillaume, M.D., L.L.C.,. Patient Signature / Authrized Representative Relatinship t Patient Date Witness Signature Date

9 Carle Guillaume, MD, FAASM Leah Luckerth, MD Phne: (913) WeHelpYuSleep.cm 8625 Cllege Blvd, Suite 103, Overland Park, KS REMedy Sleep Medicine, LLC Cancellatin and Missed Appintment Plicy At REMedy Sleep Medicine, LLC, it is ur missin t prvide skilled and individualized care fr all f ur patients. This ften means that ur appintments, and especially vernight sleep studies, are at a premium. Cancelling yur appintment r sleep study with apprpriate ntice allws us t prvide ur ther patients with quality care. Please take a mment t review ur plicies regarding cancellatins and missed appintments. Missed Appintment and Cancellatin Plicy (Office Visits): We cnsider yu t have missed yur appintment if yu have nt arrived within 15 minutes f the scheduled time. We request yu give 24 hur ntice if yu wish t cancel r reschedule yur ffice visit. We reserve the right t charge a $35 fee fr these late cancellatins and missed appintments. Missed Appintment and Cancellatin Plicy (Overnight Sleep Studies): We try t make every effrt t accmmdate yur scheduling needs, hwever, because f the limited nature f vernight sleep studies and the qualified staff needed t perfrm these studies, we require 72 hur ntice if yu wish t cancel r reschedule yur study. We require this ntice regardless f whether yur study was scheduled less than 72 hurs befre yur appintment. Withut 72 hur ntice, it can be difficult t schedule anther patient. The arrangement fr the staff invlved in perfrming and interpreting the sleep study is ften dne weeks in advance and, because f this, we reserve the right t charge a $350 fee if yu miss yur appintment withut such ntice. These fees are nt cvered by insurance and will be slely yur respnsibility. Fees will be charged t yur credit card n file withut ntice. If yu need t cancel r reschedule yur ffice visit r vernight sleep study, ur staff can be reached between 9AM and 5PM, Mnday thrugh Friday, at We believe that yur time is valuable and respectfully request yu treat urs the same way. By signing belw yu acknwledge and agree t the plicies abve. Thank yu fr yur understanding. -The Staff at REMedy Sleep Medicine, LLC. Patient Name (please print): _ Patient Signature: Date: Witness Signature: Date: