Your appointment is scheduled for at with Dr. Karl Doghramji.
|
|
- Leonard Park
- 5 years ago
- Views:
Transcription
1 Jefferson Sleep Disorders Center 443 Laurel Oak Road, 1st Floor Voorhees, NJ T F Dear prospective patient: We thank you for choosing the Jefferson Sleep Disorders Center at Voorhees; we are happy to be involved in your care. Please complete the enclosed forms and initial questionnaire and bring them with you on the day of your appointment. We understand this paperwork is extensive and will take a sufficient amount of time to complete. However it is very helpful for your sleep physician and will assist with your care. If you have any questions, please call us. Your appointment is scheduled for at with Dr. Karl Doghramji. WHAT TO BRING WITH YOU TO THE VISIT It is IMPERATIVE that you complete all enclosed forms PRIOR to your visit and that you BRING THEM WITH YOU to your initial visit. If you have had sleep studies before, please bring the results of all of your prior sleep studies with you. If you have already been diagnosed with sleep apnea, and have a CPAP machine, please bring your CPAP machine with you. If we do not already have them, please bring results of any pertinent tests performed over the past year, such as blood labs, EKG, x-rays, etc. WHAT TO EXPECT ON THE DAY OF YOUR VISIT A sleep specialist doctor will review your prior medical records, interview you, and perform a brief non-invasive physical examination. Please arrive 15 MINUTES early for your appointment. Failure to do so may cause us to reschedule your appointment. If you need to reschedule, please call INSURANCE At the time that you scheduled your appointment, the scheduler informed you of all referrals required by your insurance carrier. Please remember that most HMO patients must have a referral on file or a copy of the referral. Please bring your insurance card and driver s license to your visit. Co-payments are collected at the time of your visit. The following is a list of provider numbers that will allow you to obtain your referral: Insurance Provider ID #s NPI # NJ Medicaid Amerihealth Aetna Dr. Doghramji CS HOME OF SIDNEY KIMMEL MEDICAL COLLEGE
2 What is the main problem for which you are coming to the Jefferson Sleep Disorders Center? Do you snore? M Yes M No Do you wake others as result of your snoring? M Yes M No Do you snore louder on your back than your side? M Yes M No Do you have gaps or pauses in breathing during sleep? M Yes M No Do you wake from sleep with choking or gasping? M Yes M No Do you wake with a sour taste in your mouth? M Yes M No Do you wake with dry mouth? M Yes M No Do you wake with a headache? M Yes M No Do you kick or leg twitch during sleep? M Yes M No Do you have leg discomfort prior to or after falling asleep? M Yes M No Do you experience body rocking during sleep? M Yes M No Do you ever experience head banging/rocking during sleep? M Yes M No Do you fall out of bed during sleep? M Yes M No Have you ever experienced other body movements during sleep? M Yes M No Do you experience bed wetting during sleep? M Yes M No Do you experience loss of bowel control during sleep? M Yes M No Have you ever experienced sleep walking? M Yes M No Have you ever experienced vivid dreams? M Yes M No Have you ever experienced night terrors? M Yes M No Have you ever experienced sleep disturbed by headaches? M Yes M No Have you ever experienced paralysis during or just prior to sleep? M Yes M No Have you ever experienced sudden loss of muscle control? M Yes M No Jefferson Sleep Disorders Center page 1 of 5 FORM (REV.11/17) CS
3 Have you ever experienced sudden weakness following an emotional experience? M Yes M No Do you experience teeth grinding during sleep? M Yes M No Do you experience teeth clenching during sleep? M Yes M No Do you ever experience difficulty falling asleep? M Yes M No Do you experience difficulty staying asleep (nocturnal awakenings)? M Yes M No Do you experience restless and disturbed sleep? M Yes M No Do you experience waking early in the morning even when unnecessary? M Yes M No Have you ever experienced feeling unrefreshed after a full night s sleep? M Yes M No Do you take day time naps? M Yes M No Do you fall asleep involuntarily during the day or evening? M Yes M No Do you fall asleep or nod off while driving? M Yes M No Have you ever experienced accidents as a result of falling asleep during driving? M Yes M No Do you fall asleep while reading or watching TV? M Yes M No Do you fall asleep during conversations? M Yes M No Do you fall asleep at work? M Yes M No Do you experience inability to nap even after trying? M Yes M No Do you sleep worse while away from home? M Yes M No Do you do shift-work? M Yes M No Do you sleep in late on weekends or days off from work? M Yes M No Do you travel across times zones? M Yes M No What time do you go to bed? How long does it usually take you to fall asleep? Number of times you awaken you a typical night? Typical length of each awakening? Time of your final awakening? Time you finally get out of bed? The length of time it takes you to feel alert after getting out of bed? The time(s) when you again feel sleepy during the day? The typical length of time it takes you to feel sleepy during the day? How many naps you take during a typical day? The typical length of each nap? Do you dream during naps? Are naps refreshing? Time you would go to bed given the opportunity? Number of naps you would take, if given the opportunity? Do you sleep alone? M Yes M No Jefferson Sleep Disorders Center page 2 of 5 FORM (REV. 11/17) CS
4 Number of regular sodas (glasses) per day: Number of regular tea (cups) per day: Number of regular coffee (cups) per day: Number of chocolate (pieces) per day: Number of beer (ounces) per day: Number of liquor (ounces) per day: Please list all current medications and dosage or write No Current Medications. Please list past sleep related medications. Please list all allergies to medications or write no known drug allergies. Jefferson Sleep Disorders Center page 3 of 5 FORM (REV. 11/17) CS
5 Please describe your occupation: Please describe your leisure activities: Please indicate if you have had difficulty in any of the following areas. Please describe the difficulty Please make your choice with a check mark Never In the Past Currently Head M M M Eyes M M M Ears M M M Nose M M M Throat M M M Neck M M M Back M M M Chest M M M Heart M M M Lungs M M M Liver M M M Kidney M M M Thyroid Gland M M M Arms or Legs M M M Joints M M M Skin M M M Sexual Function M M M Vision M M M Speech M M M Urination M M M Bowel Movements M M M Jefferson Sleep Disorders Center page 4 of 5 FORM (REV. 11/17) CS
6 Fatigue Severity Scale (FSS) The FSS questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and circle a number from 1-7 based on how accurately it reflects your condition during the past week and the extent to which you agree or disagree that the statement applies to you. During the past week, I have found that: Disagree Agree My motivation is lower when I am fatigued Exercise brings on my fatigue I am easily fatigued Fatigue interferes with my physical functioning Fatigue causes frequent problems for me My fatigue prevents sustained physical functioning Fatigue interferes with carrying out certain duties and responsibilities Fatigue is among my three most disabling symptoms Fatigue interferes with my work, family, or social life FSS Score: The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Sitting and reading Watching TV Sitting inactive in a public place Passenger in a car for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch with no alcohol In a car, while stopped for a few minutes in traffic ESS Score: Patient Signature: X Date: FOR PHYSICIAN OFFICE USE ONLY I certify that I have reviewed and evaluated pages 1 through 7 with the above named patient. Physician Signature: X Date: Time: M Karl Doghramji, MD M Dimitri Markov, MD M Ritu Grewal, MD M Zhanna Fast, MD Jefferson Sleep Disorders Center page 5 of 5 FORM (REV. 11/17) CS
7 Getting to the Jefferson Sleep Disorders Center at Voorhees Conveniently located in the Voorhees Corporate Center just off of Haddonfield-Berlin Road (Rt. 561), Jefferson at Voorhees is just minutes away from major roads including I-295, the New Jersey Turnpike and Route 73. From Center City Philadelphia Take Benjamin Franklin Bridge to New Jersey. Once through the toll booths, bear right onto Route 676 South (heading toward Atlantic City). Follow Route 676 South past the Walt Whitman Bridge until signs appear for Route 295 North (toward Trenton). Follow Route 295 North to exit 31, 32 or 34A; all of these exits will bring you into Voorhees. From Exit 31 / Woodcrest Station From 295 North, take Exit 31. Go to the end of the ramp and make a left onto Melrose Avenue. (Almost immediately, you will see Woodcrest Train Station on your right.) Follow Melrose Avenue until it dead-ends at Burnt Mill Road and make a right. Follow Burnt Mill Road (past the Voorhees Town Center on the left) until you come to White Horse Road. Make a left onto White Horse Road and follow this to the entrance of the Voorhees Corporate Center. (There is an Olive Garden on the corner.) Turn right onto Laurel Oak Road (pass the Hampton Inn) and continue to Jefferson at Voorhees on your right. Turn right onto the driveway. From Exit 32 / Haddonfield - Gibbsboro From 295 North, take Exit 32. Bear to the right as you exit the ramp onto Route 561 East. (Route 561 is also known as Haddonfield-Berlin Road or sometimes just Berlin Road.) Continue east on Route 561 for approximately 3 miles (until you pass the Eagle Plaza Shopping Center on the right). At the first traffic light past the Acme, turn right onto Voorhees Road. Follow Voorhees Road to the stop sign (you will pass the Rave Cinemas movie theater on your left). Make a right onto Laurel Oak Road and then a quick left onto the driveway for Jefferson at Voorhees. From Exit 34A / Marlton From 295 North, take Exit 34A. Bear to the right as you exit the ramp onto Route 70 East. Follow signs for South Springdale Road/ Voorhees, approximately three-fourths a mile. Make a right onto South Springdale Road. Follow this road for approximately 2 miles. Springdale Road will turn into White Horse Road. Bear slight right onto White Horse Road. Continue on White Horse Road to the entrance of the Voorhees Corporate Center. Make a left onto Laurel Oak Road and continue to Jefferson at Voorhees on your right. Turn right onto the driveway. From Points East (Marlton, Atco, Berlin, Medford, Shore Points) Take Route 73 to Haddonfield-Berlin Road (Route 561) West towards Gibbsboro and Voorhees. Follow Haddonfield-Berlin Road for approximately 3.5 miles to Laurel Oak Road and turn left. (The American Water Works building is at this intersection as a landmark.) Jefferson at Voorhees is one-quarter mile on your left. Turn left onto the driveway. From Points North (Mt. Laurel, Maple Shade, Moorestown, Trenton) Take Route 295 South to Exit 32 for Voorhees. Make a left at the exit onto Route 561 (Haddonfield-Berlin Road). Continue east on Haddonfield-Berlin Road for approximately 3 miles until you pass the Eagle Shopping Center. At the first traffic light past the Acme, turn right onto Voorhees Road. Follow Voorhees Road to the stop sign (you will pass the Rave Cinemas movie theater on your left). Make a right onto Laurel Oak Road and then a quick left onto the driveway for Jefferson at Voorhees. From Points South (Lindenwold, Stratford, Clementon, Washington and Gloucester Townships) Follow College Drive/Laurel Road North until you cross over White Horse Pike (Route 30). Laurel Road becomes White Horse Road at this point. Continue onto White Horse Road for approximately 1 mile to the entrance of the Voorhees Corporate Center, which is on your right. (There is an Olive Garden on the corner.) Turn right onto Laurel Oak Road (pass the Hampton Inn) and continue to Jefferson at Voorhees on your right. Turn right onto the driveway. From Points West (Magnolia, Barrington, Audubon, Haddon Heights) Follow White Horse Pike (Route 30) to White Horse Road (you must take the right jughandle to get onto White Horse Road). Continue on White Horse Road for approximately 1 mile to the entrance of the Voorhees Corporate Center, which is located on your right. (There is an Olive Garden on the corner). Turn right onto Laurel Oak Road (pass the Hampton Inn) and continue to Jefferson at Voorhees on your right. Turn right onto the driveway. Laurel Oak Road White Horse Road Jefferson at Voorhees Haddonfield-Berlin Road Eagle Plaza Rave Cinemas Flyers Skate Zone Jefferson at Voorhees offers onsite parking. CS HOME OF SIDNEY KIMMEL MEDICAL COLLEGE
Your appointment is scheduled for at with Dr. Dimitri Markov.
Jefferson Sleep Disorders Center Dear prospective patient: We thank you for choosing the Jefferson Sleep Disorders Center, At the Navy Yard. 3 Crescent Drive, in Suite 100 (on site parking) 215-503-3300
More informationYour appointment is scheduled for at with:
Dear prospective patient: We thank you for choosing the, At the Navy Yard. 3 Crescent Drive, in Suite 100 (on site parking) 215-503-3300 We are happy to be involved in your care. Please complete the enclosed
More informationSleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
More informationSleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
More informationDenver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
More informationBaptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
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
More informationSLEEP DISORDERS CENTER QUESTIONNAIRE
Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check
More information*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.
More informationWELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
More informationPatient 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:
More informationEmergency 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:
More informationSleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
More informationPATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
More informationNarendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
More informationMaintenance for Wakefulness Testing (MWT)
SLEEP DISORDERS CENTER St. Joseph Mercy Ann Arbor 5305 Elliott Drive, Ypsilanti, MI 48197 734-712-2276 / Fax 734-712-2967 Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness
More informationPATIENT 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
More informationPATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
More information130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
More informationLittleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
Littleton, CO Welcome Packet For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 8151 Southpark Lane, Suite 200, Littleton,
More informationPATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
More informationSleep Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
More informationPATIENT 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:
More informationGeneral 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
More informationNash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:
Appointment Date: Arrival Time: *Please give at least 24 hour notice if you are unable to keep your appointment or need to reschedule. 1. Patients will need to bring pictured identification, insurance
More informationPatient History & Sleep Questionnaire
Patient History & Sleep Questionnaire Patient Full Name: Nick Name: Birth date: Age: Sex: Height: Current Weight: Weight Five Years Ago: Peak Lifetime Weight: Marital Status: Single Married Divorced Widowed
More informationPULMONARY & 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
More informationSLEEP HISTORY QUESTIONNAIRE
Date of birth: Today s date: Dear Patient: SLEEP HISTORY QUESTIONNAIRE Thank you for taking the time to fill out a sleep history questionnaire. This will help our healthcare team to provide the best possible
More informationAssociated 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
More informationMaintenance for Wakefulness Testing (MWT)
Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness Testing (MWT) will begin on the morning of at 7 a.m. and will end at 5 p.m. ARRIVAL TIME: If you are not able to arrive
More informationHumble 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
More informationPatient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ 85306 (602) 938 6960 Dear Patient, Your Doctor has requested you be scheduled for a sleep
More information604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA 70301 985-493-4759 SLEEP HISTORY QUESTIONNAIRE DATE: / / NAME: AGE (First) (Middle) (Last) ADDRESS: (Street) (City) (State) (Zip) PHONE: Home( ) Work:( )
More informationSleep History Questionnaire
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
More informationSleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
More informationHuron 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
More informationSleep Medicine Questionnaire
Please bring this completed questionnaire with you to your sleep medicine appointment. Our sleep medicine staff strives to understand your sleep symptoms, which may be complex in nature. Thank you for
More informationIntake Questionnaire
Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK=
More information493 Blackwell Road, Suite 317-A, Warrenton, VA
493 Blackwell Road, Suite 317-A, Warrenton, VA. 20186 Dear Sleep Study Patient, Attached is the patient questionnaire for your sleep study. Please complete and mail or fax the enclosed forms as soon as
More informationHuron 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
More informationSleep Study Appointment Date: Time: 8:00 PM
100 West Fourth Street, Suite 350 Cookeville, TN 38501 (931) 783-2753 Fax: (931) 783-2036 Patient Name: Sleep Study Appointment Date: Time: 8:00 PM We are located at the corner of 4 th Street and Cedar
More information993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD
993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD Atlanta, Georgia 30342 David E Westerman, MD 404-303-1700/ Fax: 404-252-9527 Alex Hebert, NP-C To our New Sleep Patient: On behalf of North Atlanta
More informationTHE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
More informationSleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
More informationOccupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
More informationTHE PERMANENTE MEDICAL GROUP
Patient label here THE PERMANENTE MEDICAL GROUP Division of Sleep Medicine COMPLETED BY: PARENT/GUARDIAN CHILD/ADOLESCENT Age: Height: Weight: PEDIATRIC SLEEP QUESTIONNAIRE Thank you completing this questionnaire.
More informationAshok 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.
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
More informationNew Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
More informationSleep Questionnaire. Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago:
Sleep Questionnaire Patient's Name: Referring Dr.: Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago: Weight 5 years ago: 5 yrs ago: 10
More informationSLEEP STUDY - PATIENT QUESTIONNAIRE
NOTE: You cannot fill out this form on Mozilla Firefox, please try another browser. You have two options for completing a questionnaire: - Enter the information on the fillable PDF and click Print at the
More informationRobert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study
NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A 811 West Interstate 20, Suite G12 Arlington, Texas 76017 (817) 419-6375 Fax (817) 419-6371 Robert E. McMichael, M.D. Medical Director
More informationSleep Medicine Associates
Date: Patient Name: DOB: Patient Height: _ Weight: _ lbs Referring Physician: Neck Size: Main Sleep Problems: 1. My main sleep complaint is: Trouble Sleeping at night Sleepy during the day Unusual behavior
More informationSleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
More informationInstructions. If you make a mistake, put an "X" over the checkmark. Then put a checkmark in the correct box and draw a circle around that box.
SLEEP HEART HEALTH STUDY SLEEP HABITS AND LIFESTYLE QUESTIONNAIRE Instructions Thank you for taking time to fill out the enclosed Sleep Habits Questionnaire. Please fill out the form completely. You may
More informationEMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
More informationWelcome to the Koala Center for Sleep Disorders
Welcome to the Koala Center for Sleep Disorders Your health is very important. We are honored to have the opportunity to join you on your wellness journey. In order to provide you with the comprehensive
More informationSLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
More informationSleep 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.
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 information1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
More informationNot Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
Health Benefits Employee Services HBE Preventive Health - Sleep Assessment Form Please bring your completed assessment form to your appointment. To schedule an appointment please call 505 844-HBES (4237).
More informationPre-Test Questionnaire. Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over
Pre-Test Questionnaire Date: Hospital # (Please Print) Name: Sex: Age: Date of Birth: Height: ft. in. Weight: lbs Gain? Loss? of lbs over Chief Complaints What problem(s) brings you to sleep disorders
More informationTallahassee 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)
More informationPEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
More informationMICHIGAN 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
More informationGeneral Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
More informationBMI: Family physician : Neck circumference (cm) Hypertension + 4 cm Snoring + 3 cm Witnessed apnea + 3cm Total
Last and first names: F M Date: Date of birth: / / YYYY MM DD Weight: kg /lbs Profession/job: Height: _ cm /ft.in. BMI:_ Family physician : ANC (adjusted neck circumference) : Neck circumference (cm) Hypertension
More informationSection of Pediatric Sleep Medicine
Section of Pediatric Sleep Medicine David Gozal, MD Hari Bandla, MD Date: Dear Parent or Caregiver; Thank you for your interest in the Sleep Disorders Program. The sleep clinic s standard assessment procedure
More informationSleep Center New Patient Questionnaire
For office use only Appt date: Sleep Center Clinician: Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 #1 respiratory hospital
More informationBrunswick Pulmonary and Sleep Medicine Lawrence Davanzo, DO, FCCP 49 Veronica Ave, Somerset, NJ Phone# Fax#
REGISTRATION FORM (Please Print) Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid If not, what is
More informationPATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
More informationPATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
More informationWhat s the name of your position?
What s the name of your position? What are some basic work responsibilities (e.g primarily front desk/administration, light lifting or heavy liftingplease indicate pounds)? CONSENT FORM FOR USE AND DISCLOSURE
More informationSubscriber 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
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 informationYOUR NAME AGE DATE. Comments. Describe your sleep problem and how long you ve had it
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 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 informationDear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology.
Dear Patient: You have an appointment scheduled with SIMEDHealth Pulmonology. You should read through this package and complete all indicated areas. Some paperwork is related to your health history, some
More informationSLEEP 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
More informationSleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?
Onslow Medical Specialties Clinic Lung Diseases & Sleep Disorders Clinic Pulmonary Function Test/ CardioPulmonary Exercise Test/ Thoracic Ultrasound Methacholine Challenge Test/ Video-Flexible Laryngoscopy/
More informationThe following questions are about your sleep. Please consider both what others have told you about your sleep and what you know yourself.
Sleep History Form FORM CODE: SLE VERSION A 1/29/2009 PARTICIPANT ID NUMBER: CONTACT YEAR: 0 9 LAST NAME: INITIALS: INSTRUCTIONS: This form should be completed during the participant's clinic visit. ID
More informationEPWORTH SLEEPINESS SCALE
EPWORTH SLEEPINESS SCALE Name: Sponsors last 4 of SSN#: DOB: Today s Date: Age (years): Gender (circle): MALE FEMALE How likely are you to doze off or fall asleep in the following situation, in contrast
More informationPlease complete this questionnaire before your appointment.
Date completed: Please complete this questionnaire before your appointment. Name: Occupation: Age: Birth date: Gender: M / F Height: Weight: Weight in High School: Neck Size: in. Ethnicity: Hispanic or
More informationRoom # Critical Care & Pulmonary Consultants, P.C.
Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate
More informationHuron 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
More informationPATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
More informationYour physician has ordered a sleep study for you on. Your arrival time is scheduled for.
Dear Patient: Your physician has ordered a sleep study for you on. Your arrival time is scheduled for. The Texas State Sleep Lab is located in the Health Professions Building on the Texas State University
More informationArizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
Patient Information Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305 Home Phone: Cell Phone: Last Name: First Name: MI Mailing Address: APT City/State/Zip Sex: Male Female Birthdate:
More informationMEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
More informationDESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
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
More informationPlease answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services.
Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services. Pa ent Iden fica on: Pa ent name: Date: Age: Date of birth: Who is filling out this ques onnaire? Please
More informationRiley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like t like
More informationSleep Screening Questionnaire
Version: SLPQV1 Sleep Screening Questionnaire OFFICE USE Patient ID: NAME: CURRENT DATE: / / DATE OF BIRTH: / / MALE FEMALE Referring Physician: Contact ID: Number Number #1 = the most severe symptom #1
More informationPolysomnography Patient Questionnaire
Polysomnography Patient Questionnaire Date Medical Record # Demographics: Patient Name Date of Birth Address_ Home Phone Work Phone Cell Phone Height Weight Please complete each section of this questionnaire,
More informationHome Sleep Testing Questionnaire
Home Sleep Testing Questionnaire Patient Name: DOB: / / Gender: Male Female Study Date: / / Marital Status: Married Cohabitate Single Divorced Widow/Widower Email: Phone: Height: Weight: Neck Size: What
More informationSouthwestern 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
More informationFacial Problem(s) Questionnaire
Facial Problem(s) Questionnaire Full Legal Name: _ Birth Date: Referred by: Referring Dr s Phone#: Referring Dr s Email address: _ Christopher M. Anderson, DMD 1225 Johnson Ferry Road Suite 660 Marietta,
More informationHeight: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other
Personal Information Name: Date of birth: Sex: Male Female Marital Status: Nationality: MRN(for KAUH Patients): Height: Weight: Neck Size: Address: Occupation: Length of work day: Does your work involve
More informationSLEEP 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
More informationSLEEP CENTER OF KENTUCKIANA 7926 Preston Hwy. Suite 200 Louisville, KY Tel: (502) Fax: (866)
Patient Information First Name MI Last Name Age Date of Birth Social Security # Work Sex Male Female Home Phone Cell Phone Next of Kin Relation Phone Number Address City State Zip Code Employer Employer
More information