Robert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study
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1 NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A 811 West Interstate 20, Suite G12 Arlington, Texas (817) Fax (817) Robert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study When you enter the parking lot, go around the west side of the building to the back (the north side). You will see a series of suites with glass doors on the ground level. Our back door is next to the last door just beside the outside stairwell. Our suite is G-12. If you have any questions, special needs, or are unable to keep this appointment, please call (817) before 5:00 PM. If you are calling after business hours, please leave a message and your call will be returned on the next business day. Enclosed you will find instructions to follow the day of your test, an information sheet explaining the procedure, and questionnaires. To assist us your evaluation, please complete the questionnaires and bring them with you to the sleep lab on the night of your test. On the day of your test, please follow the instructions listed below: Avoid caffeine-containing products such as coffee, tea, or carbonated soft drinks after lunch. Do not take any naps the day of the test. Take all prescribed medications, as ordered. If you are scheduled for a daytime sleep test on the day following your nighttime test your meals will be provided. Please bring comfortable clothes for your naps, such as sweats, shorts, etc. You will need to stay awake between your naps. If you are scheduled for daytime testing for Narcolepsy, please provide a list of medications to the sleep center two weeks prior to your test. Some medications can affect the test. Bring comfortable sleeping attire, such as shorts and a T-shirt, pajamas, nightgowns, bathrobe, slippers, etc. (No silky material or tight leggings, please). Bring any items you may need to wash and dress in the morning, such as toothbrush, facial soap, shaving equipment, blow dryer, etc. We have full bathrooms with showers. Women: If you have acrylic nails, please remove one of them. We monitor your oxygen level and the sensor does not read accurately through the artificial nail. Before coming to your appointment, please shower and shampoo your hair. Please do not apply any conditioners, creams, oils or dressings to you hair or skin. Page 1
2 North Texas Sleep Disorders Center Sleep Study Information The purpose of the sleep study is to look for any respiratory, neurological, or physical problems that occur during sleep. These may cause either an inability to sleep or excessive daytime sleepiness. This is a diagnostic tool. It is not a treatment for your problem. If you have not already completed your questionnaire, you will be asked to fill one out prior to the testing. When you come to the sleep center, the technologist will attach monitoring electrodes to your scalp and chin using a conductive paste. The paste is easily dissolved with warm water. Tape is used to attach electrodes around your eyes and on your legs during the night. Electrodes to monitor you heart are attached to your chest. Stretchy bands will be placed around your chest and abdomen to monitor respiratory effort. A small sensor is taped under your nose that monitors airflow from your nose and mouth. Oxygen in the blood is evaluated by attaching a sensor to one of your fingers. This device shines a small light through the tissue of the fingers and measures how much oxygen is in the blood. After all the electrodes are attached they are plugged into a box, which is connected to a computer. This is where the information will go during the night while you are sleeping. Once the study has started, if you wake up and need to use the bathroom or get out of bed for any reason, you must call the technologist. The wires to the box are too short to allow you to get up without assistance. There is an intercom in your room, which will allow the technologist to hear you. To alert the technologist, simply call and someone will be in to assist you. If you do not get an immediate response, please call again. The technologist may be with another patient and temporarily unable to respond immediately. Do not try and get out of bed by yourself. Page 2
3 NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A. 811 W. Interstate Highway 20, Suite G12 Arlington, TX (817) Fax (817) Sleep History Name Date of birth Address Phone Home Cell Work Sex Male Female Marital Status What is your main sleep problem? When did this begin? Describe any current or past treatment for sleep problems. What doctors or clinics have treated you for sleep problems? When do you go to bed? Weekdays AM or PM Weekends AM or PM When do you get up? Weekdays AM or PM Weekends AM or PM Circle any of these things that you do in bed: watch TV listen to radio read eat do work How long does it usually take to fall asleep? How many times do you wake up at night? How long does it take to go back to sleep? How long do you stay in bed after awakening before you get up? How many hours of sleep do you generally get? How do you feel when you get up? Completely rested Partly rested Not rested at all Page 3
4 Name Identify any medication you often take to sleep. How often do you take naps? How long are your naps? How much do you drink of the following? Do not count decaffeinated drinks. Regular coffee Tea Cola, Dr. Pepper, Mountain Dew Energy drinks with caffeine _ Alcoholic beverages Work Schedule What are your usual work days and work hours? Please describe shift changes, if any. Please circle any of the following that apply to you. Daytime drowsiness Snore Wake up snoring Have been told that you stop breathing in sleep Wake up gasping Wake up with a dry mouth Doze off while driving Doze off at a stop light Fall asleep during physical activity Very frequent night sweats Nightmares Wake up screaming Act out dreams Fall out of bed Kick during sleep Punch during sleep Frequently talk in your sleep Get out of bed while still asleep Wake up extremely confused Intrusive thoughts before falling asleep Difficulty maintaining sleep Vivid dreams right after awakening Vivid dreams just before falling asleep Hallucinations right after awakening Hallucinations just before falling asleep Wake up unable to move Go limp when startled, excited, or angry Grind your teeth at night Crawling feeling in legs at night Cannot keep legs still at night Limb jerks disturb sleep Daytime restless legs Page 4
5 Name Epworth Sleepiness Scale In contrast to just feeling tired, how likely are you to doze off (even momentarily) or fall asleep in the following situations? Even if you have not done some of these things recently, think back how they would have affected you. Use the following scale to choose the number that applies to 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 television Sitting inactively in a public place (e.g. a theater) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) In a car, while stopping for a few minutes in traffic Chance of dozing Total Page 5
6 NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A. 811 West Interstate Highway 20, Suite G12, Arlington, TX (817) Fax (817) One Week Sleep Log Name Date Bedtime Time to fall sleep Time to get up Total hours of sleep Page 6
Humble Dreams Sleep Center. Humble, TX 77339
Humble Dreams Sleep Center 8901 FM 1960 Bypass West, Ste. 306 Humble, TX 77339 Dear Humble Dreams Sleep Study Patient, Thank you for allowing Humble Dreams Sleep Center to provide your sleep study as requested
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
Sleep Study Information Metroplex Hospital Sleep Center 2111 S. Clear Creek Rd. Killeen, TX 76549 (254) 519-8452 Report to sleep lab at your scheduled appointment time, do not arrive before this time.
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 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:
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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
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
Denver, CO Welcome Packet
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Nash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:
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Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
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THE PERMANENTE MEDICAL GROUP
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Maintenance for Wakefulness Testing (MWT)
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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
*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.
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Date of Study: Arrive at: P.M.
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Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
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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.
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:
The Medical Center Sleep Center
The Medical Center Sleep Center Date: / / Name: Age: (First) (M.I.) (Last) Address: (Street / P.O. Box) (City) (State) (Zip) (County) Phone: Home ( ) Work ( ) Date of Birth: / / Education: Marital Status:
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
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 Studies Sleep studies are tests that measure how well you sleep and how your body responds to sleep problems. These tests can help your doctor find out whether you have a sleep disorder and how severe
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 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
Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:
PATIENT INFORMATION (Please Print) Today s Date : Patient s last name: First: Middle: M Jr. Sr. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your
What to Expect When Having an EEG at UVA Medical Center. Follow along as Emma comes to UVA for her EEG.
What to Expect When Having an EEG at UVA Medical Center Follow along as Emma comes to UVA for her EEG. You will be having a test called an EEG. 1 Emma stops at the Information Desk in the Primary Care
Sleep Disorders Questionnaire
Sleep Disorders Questionnaire NAME: DATE: ADDRESS: DATE OF BIRTH: AGE: SEX: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: SINGLE: MARRIED: WIDOW(ER): DIVORCED: SEPARATED: REFERRING PHYSICIAN: ADDRESS:
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
SLEEP QUESTIONNAIRE. Please briefly describe your sleep or sleep problem:
SLEEP QUESTIONNAIRE Your answers to the following questions will help us to obtain a better understanding of your sleep problems. Please answer every question to the best of your ability. It is helpful