Date of Study: Arrive at: P.M.

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1 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 (wheelchair, help using the restroom, hearing interpreter, etc.) so that the appropriate arrangements can be made. BEFORE YOU ARRIVE AT THE SLEEP CENTER: Do NOT drink caffeinated products after PM on the day of your test. Do NOT use lotions, oils, hair sprays or powders on your scalp or skin. Do SHAVE if you have facial hair Do bring your identification and insurance Do bring a comfortable pair of pajamas or shorts (no sweats or silk pj s) Do bring any medications you take at night Do bring your completed sleep paperwork packet Do NOT BRING any valuables with you to the sleep center WHEN YOU ARRIVE AT THE SLEEP CENTER: Please arrive at your scheduled time unless other arrangements were made in advance. There are no personnel in the sleep center prior to 8: PM. You will have ample time to ask questions There are forms to complete and the technician will review your health history to assist our Specialist in your diagnosis There may be a waiting period before the technician prepares you for testing and during this time you may read or watch T.V. until hookup. T.V. AND LIGHTS OUT IS PROMPTLY AT :PM Please turn off cell phones and watch alarms WHAT WILL HAPPEN DURING TESTING? Approximately two dozen electrodes, blets and various sensors will be applied to your head and body using paste adhesive and tape. The electrodes and sensor monitor your brain waves, muscle, 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-

2 eye movements, breathing, snoring, heart rate and level of oxygen. None of these sensors are painful. While you are asleep, the technician will be monitoring your sleep throughout the night. If you are scheduled for a CPAP test (Continuous Positive Airway Pressure) you can expect a mask that fits over your nose and a machine that uses room air. WHAT IF I NEED TO USE THE RESTROOM DURING THE NIGHT? All you have to do is tell the technician that you need to use the restroom. The technician through the microphone, respond that he/she is coming and enter the room to disconnect cables so that you can get up and use the restroom. This only takes a moment. HOW LONG BEFORE I RECEIVE RESULTS FROM MY SLEEP It will take approximately 7- working days for the test results to be read and sent will be contacted by our office if you need further testing or CPAP/BIPAP set-up. provide you with any information about your sleep study. WHAT ABOUT CANCELLING A STUDY? If you need to cancel your appointment, you must give the sleep center a 4 hour notice. A $5 fee will be charged for no shows or late cancellations a 4 HOUR notification. This fee is not covered by Medicare or commercial insurance. To reschedule your study please call (78) IS MY STUDY COVERED BY MY INSURANCE? Sleep studies are covered under most insurance plans, although deductibles and percentages of vary. Our officewillverifyifpriorauthorizationisneeded andthatsleepstudiesare covered plan. Your insurance will be billed directly for these tests. Details regarding coverage should to your insurance company. 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-

3 SLEEP QUESTIONNAIRE Name: Today s Date: Birthdate: Age: Sex (M or F) Height Weight _ Collar/ Neck size (inches) _ Medication you are currently on (include over-the-counter): _ Medical Conditions: (circle if applicable) High blood pressure Seizures/ Epilepsy Heart Disease Diabetes Sleep Apnea Lung disease Stroke Other: EPWORTH SCALE How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Use the following scale to choose the most appropriate number for each situation. = would never doze = moderate chance of dozing = slight chance of dozing = high chance of dozing SITUATION CHANCE OF DOZING Sitting and reading Watching television Sitting, inactive in a public place (i.e. theater or meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon (when circumstances permit) Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic SCORE:_ DAYTIME SLEEPINESS Place a check beside any of the following statements that apply to you. _ I have (sometimes/always) fallen asleep at very inappropriate times (ex. Driving, eating, during a conversation etc.) _ I have (sometimes/always) been very tired/sleepy that I become confused and/or loose track of topic during a conversation. _ I am frequently tired/sleepy during the day that my work is poor. 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-

4 _ I have had a accidents or near-accidents due to feeling tired/sleepy. _ When I don t have plans the next day, I usually go to bed late. (compared with my usual bedtime) _ I frequently do not feel sleepy at bedtime and stay up late. (hence, I don t sleep a full night 68hrs) SLEEP WAKE QUESTIONNAIRE Name: Date: * ************************** *********** **** *** ********* *** *** * MY MAIN CONCERN IS: YES NO - I have trouble sleeping at night - I am sleepy all day - I have unwanted behaviors when I am sleeping If yes, explain: TYPICAL SLEEP HABITS - On weekdays, I usually go to bed at: _ - On weekdays, I wake up at: - The amount of time that I usually take to fall asleep is: 4 - My usual weekend bedtime is: 5 - I take a nap about days each week. 6 - After taking a nap, I usually feel: refreshed groggy or sleepy 7 - The number of times that I typically wake up during the night is: _ 8 - The reason I wake up is: 9 - On weekends, I wake up at: 4 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-

5 : - To feel my best, I should go to bed at: - To feel my best, I should get up at: _ - In the evening, I usually start feeling tired at: - I usually exercise at for minutes. 4 - I wake up naturally; by using alarm. SLEEP WAKE QUESTIONNAIRE Name: Date: * ************************** *********** **** *** ********* *** * * * * DISTURBED SLEEP happiness by my snoring I have been told that I snore very loudly I sometimes awaken with a choking sensation I have been told that I stop breathing when I sleep I have fallen out of bed I have been told that I make rolling or rocking movements during sleep I sometimes have felt paralyzed or unable to move when waking or falling asleep I wake up suddenly from sleep with an unpleasant feeling of fear, anxiety, tension, or I have awakened from sleep (once or more) having vomited or had heartburn When I wake during the night, l often have to use the bathroom I tend to sweat a lot while asleep I feel that the quality of my sleep is unsatisfactory I have been told that my legs twitch or jerk while sleeping Occasionally I wake up with a headache/migraine Sometimes people can t sleep in the same room with me because they are bothered My bed covers are very messy in the morning I am a restless sleeper I have been told that I kick or poke my bed partner while I sleep 5 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-

6 I have a job that involves various shift schedule changes I frequently travel across time zones (east-west travel) I feel that sleep is a waste of time My usual sleep position is: on my back on my side (circle one): right or left on my stomach no single position I remember dreaming: rarely about once a week a few times a week nearly every night Typically my dream recall is: only a vague feeling of having dreamed something a sketchy story, image or thought a fairly detailed and complex recollection In the morning during the first minutes after I wake up I usually feel: very groggy somewhat drowsy slightly drowsy but awake alert and active SLEEP WAKE QUESTIONNAIRE Name: Date: * ************************** *********** **** *** ********* *** *** * PARASOMNIAS I have been told that I grind my teeth when I sleep As an adolescent or child, I have been seen sleepwalking My dreams are often very vivid I feel that I dream too much I often have frightening dreams My dreams have awaken me As an adult, I have wet my bed I have been told that I bang or twist my head at night 6 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-

7 I have hallucinations or dreamlike images when I am not actually asleep but while falling asleep or waking up INSOMNIA I have trouble falling asleep at night When I do not sleep, I worry about it the next day When I wake up during the night, I have trouble going back to sleep I wake up in the morning long before I have to Some nights, I never get to sleep no matter how hard I try When I try to go to sleep, my mind races with many thoughts At night when I go to bed, I do not feel sleepy I often sleep better in an unfamiliar bedroom, such as a hotel or motel room When I try to fall asleep I become anxious or nervous When I try to fall asleep I worry about whether or not I can sleep When I try to fall asleep I often feel hungry or thirsty I feel pain when I attempt to fall asleep Pain sometimes/often wakes me up or keeps me from going back to sleep I have a creepy, crawling sensation in my legs when I lie down to sleep When I do sleep, I feel I have slept very well I am a very light sleeper and easily awake up My sleep is disturbed because of my bed partner Hot or cold weather disturbs my sleep Generally I get up in the middle of the night for a snack Other members of my family have been hyperactive or hyperkinetic as children Other members of my family have the same problem that I do 7 84 Southwest Highway, Suite Palos Heights, IL 646 Phone: (78) Fax: (78) 77-