PRE SLEEP QUESTIONNAIRE
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1 PRE SLEEP QUESTIONNAIRE Date: Study #: RM#: Has anything changed medically since you last saw the doctor? Do you need to be awakened at a certain time? How do you feel right now? (check only one) Feeling active, wide awake Very awake, but not at peak Awake, but not fully alert A little foggy Foggy, difficult to stay awake Very sleepy, prefer to lie down Cannot stay awake If so, when? Did you feel sleepy today? No Yes At what time? Did you nap today? No Yes At what time? Did you drink alcohol today? No Yes At what time? What? How much? Did anything out of the ordinary happen today? If so, what? Please list all medication taken today including nonprescription. 1) 2) 5) 6) 9) 10) 3) 7) 11) 4) 8) 12) Rev Jul 08 SCC00003A
2 How do you feel right now? (check only one) Feeling active, wide awake Very awake, but not at peak Awake but not fully alert A little foggy Foggy, difficult to stay awake Very sleepy, prefer to lie down Cannot stay awake POST SLEEP QUESTIONNAIRE How long did it take you to fall asleep? hours minutes Was this: longer than usual shorter than usual about the same time Did you wake up during the night? If so, how many times? Were you awake: longer than usual shorter than usual about the same time How long did you sleep last night? hours minutes Was this: How did you feel longer than usual shorter than usual about the same time more rested than usual less rested than usual about the same Did you dream last night? If you had difficulty falling asleep last night, can you attribute this to anything that happened yesterday? Was there anything different about sleeping in the lab? Please list any comments: Rev Aug 05 SCC00003B
3 Sleep Study Communication & Billing Insurance Company: Verified: Study Date: Precertification required? Precert # Validity: Reason for study: Appointment confirmed for 20:00 hours: Room #: Was patient advised of possible MSLT? Chart #: DONE Physician / Number: Dr. Houston / Physician / Number: Dr. Stubler / nd night / FU PAPNAP SPECIAL INSTRUCTIONS MSLT No MSLT Do MSLT if negative or marginal study Possible split night study ** For summary of problem list please see H&P COMMENTS: BILLING: Type of study: NPSG NPSG CPAP CPAP SPLIT MSLT MWT PAPNAP less 6hr Greater 6hr less 6hr Greater 6hr BCBS BCBS BCBS BCBS BCBS NPSG CPAP MSLT MWT PAPNAP Order Date / By: Tracking By: Dev: 2015 Activated Account / By: Re Check Account / By: SCC00015
4 PHYSICIAN S NOTES Room # Study # Date Type of Study INTERPRETATION ICSD ICD 9 Description / PLAN Obstructive Sleep Apnea Syndrome Complex Sleep Apnea Hypersomnia with Sleep Apnea Insomnia with Sleep Apnea Central Sleep Apnea Syndrome Upper Airway Resistance Syndrome Crescendo Snoring with Arousals Primary Snoring CPAP/BiPAP Narcolepsy Cataplexy/Narcolepsy Idipathic Hypersomnia Hypersomnia NEC Periodic Limb Movement Disorder (Myoclonus) Restless Legs Syndrome Persistent Disorder to Initiate/Maintain Wakefulness Somnambulism or Night Terrors Sleep Bruxism Sleep Talking Dysfunction Sleep Stages/Arousal NEC Repetitive Intrusions of Sleep Dysfunction Associated with Sleep Stages or Arousals {mild mild/moderate } {moderate mod./severe } {severe } Alpha Intrusion {mild moderate severe} Physician Michael P. Houston, M.D. DEA BH UPIN C73488 r*op2023*r OP2023 Developed 1/03 SCC00005
5 Arrived in lab at Alone Escorted by: Night Note Communication Oriented to lab Fall Prevention Bedtime Awaken Perform pain assessment Medication changes since H&P Patient educated on procedure Patient viewed education video Educated on PAP / humidifier Consent for treatment / video signed Head hook up started at Lights Off Lights On PAP trial / Interfaces shown / Describe difficulties: Type of Interface chosen: CPAP Range: Bi Level: Size: Reason Change from CPAP to Bi Level: Heart rate range: Respiratory rate range: Snores detected: Snores eliminated at: Patient s sleeping positions: Patient reminded of second night / follow up on: Patient admits awake and safe to drive (if applicable): Night Notes: Tech Revised: Jan 2015 Date scc00007
6 NIGHT NOTES Date: Room # Study #: Rev Aug 05 SCC00008
7 Date: Sleep Evaluation Center Pain Assesment Tech: Do you have ongoing pain problems? Yes No Do you have pain now? Time: Pain level (0 10) If pain level greater than 3, complete the assessment below. If pain level greater than 7, contact physician on call. Location Pain Site A Pain Site B Pain Site C Duration Symptoms Describe the pain Action Taken Reassessment Do you have ongoing pain problems? Yes No Do you have pain now? Time: Pain level (0 10) If pain level greater than 3, complete the assessment below. If pain level greater than 7, contact physician on call. Location Pain Site A Pain Site B Pain Site C Duration Symptoms Describe the pain Action Taken Reassessment Dev 0804 rev 9/05 SCC00009
8 Sleep Center of the Coast Patient Consent for Photography / Videography I authorize and consent to having photographs / video footage taken of me by personnel of the Providence Hospital Sleep Evaluation Center. In understand that these photo graphs / videos are for diagnostic purposes and will be used in conjunction with my medical evaluation. The photograph of me will remain a part of my medical record. The video will be kept for 15 days, and if not needed for diagnosis, will then be destroyed. I further understand that in some instances the video may be used for teaching purposes. I hereby forever waive and release to Providence Hospital or its designee any property rights, whether created by common law or statute, which I may have or may acquire to the photographs / videotapes taken of me or other information obtained from me while a patient at Providence Hospital. I understand that this waiver and release that the above referenced items are the exclusive property of Providence Hospital and that it may use or otherwise dispose of these photographs / videotapes or related information, without further approval or consent by me and free of any claim on my part. Signature* Date Witness * Because the above patient is an unemancipated minor, years of age, or is unable to sign for the following reasons: The above consent is given on the patient s behalf by: Witness Closest Relative or Legal Representative Date Relationship Dev 1/98; Revised 6/05 SCC00013
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