Huron Medical Sleep Center Saad S. Ahmad, MD
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1 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 and video monitoring during my sleep study. I have received and understand the instructions for the sleep study. In addition to the ordering provider, I consent to discussion of sleep study results to spouse and next of kin. ( If you do not wish us to discuss results with spouse or next of kin, please check the following box and write the names of the persons you do not wish us to discuss your results with. I release Dr. Saad S. Ahmad / TriCity Lung Associates, PLC from any responsibility that may arise from the release of these records. I authorize Dr. Saad S. Ahmad / TriCity Lung Associates, PLC to release information contained in my medical records, including as applicable: Alcohol and drug abuse and mental health treatment information protected under the regulation title 42 of the code of Federal Regulations Part 2, information about communicable diseases and infections, as defined by Department of Public Health rules ( Michigan Public Health Code) Which includes venereal disease, tuberculosis, Human immunodeficiency virus-hiv, acquired immunodeficiency syndrome-aids and AIDS related complex-arcthis consent will expire on the year after the date signed. Patient Name (PRINT) Date of birth: Signature of parent or guardian: Date:
2 Pediatric Sleep Questionnaire Please state, in your own words, the reason why you (or your doctor) contacted our clinic: At what age did this problem begin? Has it changed? NO / YES: How? MEDICATION ALLERGIES: CHILD S CURRENT HISTORY - MY CHILD HAS THE FOLLOWING: Asthma Sounds congested Has frequent ear infections Frequent strep throat Has frequent colds Acid reflux Chronic bronchitis Heart problems Neurological problems Bipolar/Depression ADHD/ ADD/ ODD Down s Syndrome Delayed growth Developmental delay Prader Willie Learning disability Autism Allergies Thyroid problem Epilepsy/ Seizures CHILD S FAMILY HISTORY Does anyone in your family, have a sleep problem? Describe whom and type of problem:
3 MEDICATIONS: Please list the name and doses of all medications taken now, or that have been taken within the last 30 days: MEDICATION NAME DOSAGE (MG) REASON Past Medications: Name of all medications the patient has taken within the last year: MEDICATION NAME DOSAGE (MG) REASON Ears, Nose and Throat Surgeries) Adenoids and tonsils removed? Yes or No Date: Surgeon: Others: Yes or No Date: Surgeon: Child s birth information: Was this a normal delivery? Born earlier than due date? NO / YES: Explain: NO / YES: How much earlier? Was oxygen needed at birth? NO / YES: Tube feedings? NO / YES ; Extended stay after birth? NO / YES: How long?
4 CHILD S SOCIAL HISTORY Caffeinated beverages (Cola, Mountain Dew, iced tea): /day (amount) Child s grades: Is your child enrolled in a special education class? Y/ N Members of the family living with the child in the same House: Indoor Pets: Does anybody smoke in the house? SLEEP SCHEDULE WEEKDAYS WEEKENDS/VACATIONS 1. Child s usual bedtime AM/PM AM/PM 2. Child s usual awake time AM/PM AM/PM 3. Child s sleep duration per night? HOURS HOURS 4. Time to fall asleep? MIN MIN 5. Number of awakenings each night? TIMES 6. Duration of awakenings? HOURS/MIN NAPS Number of days each week your child takes a nap. Usual nap times. Nap1: Nap2: Nap3 ABOUT FALLING ASLEEP 1. Does the child have a regular bedtime routine? YES/ NO 2. Does the child have his/her own bedroom? YES / NO ; His/Her own bed? YES / NO
5 3. Is a parent present when your child falls asleep? YES /NO 4. Child usually falls asleep in: Own room in own bed (alone) Parents room in own bed Parents room in parents bed Sibling s room in own bed Sibling s room in sibling s bed 5. Child sleeps most of the night in: Own room in own bed (alone) Parents room in own bed Parents room in parents bed Sibling s room in own bed Sibling s room in sibling s bed 6. Child usually wakes up in the morning: Own room in own bed (alone) Parents room in own bed Parents room in parents bed Sibling s room in own bed Sibling s room in sibling s bed 7. Child resists going to bed? YES / NO 8. Child has difficulty falling asleep? YES / NO 9. Uncomfortable feeling in child s legs/arms such as creepy/crawly feeling? YES / NO ABOUT SLEEP (check all that are true) 1. Child is a poor sleeper? YES / NO 2. Child has a restless sleep? YES / NO 3. During sleep, my child: (check all that are true) Snores Stops breathing Has night terrors Snores loudly Looks pale or blue Sleepwalking Snores continuously Sweats when sleeping Sleep talking Gasps for air Wets bed Nightmares Makes choking sounds Rocks his/her body Grinds his/hers teeth Has a heavy breathing Kicks legs in sleep Get out of bed at night Struggles breathing Bang his/her head Uncomfortable feeling in child s legs; creepy or crawly feeling.
6 ABOUT AWAKENING (check all that are true) Is difficult to awaken in the morning Is difficult to get out of bed in the morning Headaches in the morning Seems groggy in the morning Complains of feeling tired Bed sheets found disorganized Has no appetite in the morning Has trouble getting dressed DURING THE DAY (check all that are true) Is on the go and acts as if driven by a motor Is easily distracted by extraneous stimuli Breathe through the mouth Swallowing problems Is sleepy during the day Reports unable to move when falling asleep or upon awakening Sees frightening visual images before falling asleep or upon awakening Becomes weak/looses muscle tone, when excited, angry or laughing (jaw or head dropping, knee buckling, falling on the floor, difficulty talking) for1-2 minutes? For children over 5 years of age: My child: (check all that are true) Seems hyperactive Is impulsive Has behavioral/acting problems Becomes easily upset Falls asleep in school Does more poorly at school than expected Learning problems Seems very sensitive Seems excessively anxious Has difficulty making close friends Falls asleep in odd situations or places Has problems with attention
7 Additional Comments: EPWORTH SLEEPINESS SCALE In contrast to just feeling tired, how likely is your child to doze off or fall asleep in the following situations? 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. SITUATION 0 = WOULD NEVER DOZE 1 = SLIGHT CHANCE OF DOZING 2 = MODERATE CHANCE OF DOZING 3 = HIGH CHANCE OF DOZING CHANCE OF DOZING Sitting and Reading circle one Watching TV circle one Sitting inactive in a public place (i.e., in a theatre) circle one As a car passenger for an hour without a break circle one Lying down to rest in the afternoon circle one Sitting and talking to someone circle one Sitting quietly after lunch (without alcohol) circle one In a car, while stopping for a few minutes in traffic circle one TOTAL SCORE =
8 Sleep Log Complete this sleep log as instructed using the directions provided below. Complete the log in the morning and in the evening. Write additional comments on the back. a BLACKEN in the times when you are sleeping. b DOWN ARROW indicating the time you are in bed to sleep. c UP ARROW indicating when you got out of bed. Example: 8am 10am Noon 2pm 4pm 6pm 8pm 10pm MN 2am 4am 6am 8am 10am In the sample sleep log, this person got out of bed until 9am. Then he/she laid in bed for an afternoon nap at noon and fell asleep within minutes. When he/she woke up at 2pm, he/she immediately got out of bed. In the evening, this person went to bed at 9pm, but did not fall asleep until 10pm. During the night, this person was awake from 4am to 5am, but did not get out of bed. Again, he/she slept until 8am and got out of bed at 9am. **Please fill out this sleep study- recording your sleep routine for the week prior to your sleep study** DAY 8am 10am Noon 2pm 4pm 6pm 8pm 10pm MN 2am 4am 6am 8am 10am ***Please Complete This Questionnaire and Bring It with You on the Night of Your Study. *** If You Have Any Questions, Please Feel Free To Call Us
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
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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
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OREGON HEALTH & SCIENCE UNIVERSITY SLEEP DISORDERS MEDICINCE CLINIC PEDIATRIC SLEEP QUESTIONNAIRE SCHOOL AGED CHILDREN (4 12 year old) TO BE COMPLETED BY PARENT NAME OF PATIENT: DATE OF BIRTH: / / NAME
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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
More informationOriginal 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
More informationDate 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
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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
More informationI 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
More informationMEDICAL HISTORY QUESTIONNAIRE
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More informationYour 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.
More informationPatient Questionnaire
Patient Questionnaire Name: Date of Birth: Today s Date: What is your main sleep complaint and how long has it occurred? Have you ever had a sleep study before? If yes, please tell us when and where it
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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
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YOUR NAME AGE DATE Describe your sleep problem and how long you ve had it Have you ever been at a sleep center before? YES NO When? Where? Ever been on CPAP? YES NO WORK SCHEDULE When does your usual work
More informationST CHARLES HOSPTIAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE. Patient Name: Date of Birth: SS# Address: Male Female
ST CHARLES HOSPTIAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE Patient Name: Date of Birth: SS# Address: Male Female Email address Home Telephone #: ( ) Cell Phone: # ( ) HOW DID YOU HEAR ABOUT US? Referred
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