Sleep Patient Registration

Transcription

1 Sleep Patient Registration Name: Birthdate: Age: City, State, Zip: If patient is a minor, parent or guardian name: Home Ph: Work Phone: Cell: Social Security#: E- Mail: Gender: Female Male Married Single Divorced Separated Widowed Person financially responsible for this account: Phone: Emergency Contact: Emergency Phone: Employed Not Employed Student Status: Full- Time Part- Time Height: Primary Medical Insurance Insurance Company: Phone: Subscriber: Policy#: Group#: Subscriber's SSN: Subscriber DOB: Subscriber's Employer: Patient Relationship to Subscriber: Self Spouse Child Other (If other, please specify ) Secondary Medical Insurance Insurance Company: Phone: Subscriber: Policy#: Group#: Subscriber's SSN: Subscriber DOB: Subscriber's Employer:

2 Patient Relationship to Subscriber: Self Spouse Child Other (If other, please specify ) Medical History Questionnaire Patient Name: DOB: / / Form Date: / / Allergens No known allergies Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills Barbiturates Metals Sulfa drugs Codeine Penicillin Current Medications Medicine Dosage/Frequency Reason Medical History Significant Current Date/Note Significant Current Date/Note Medical Condition Never Past Medical Condition Never Past Acid Reflux Anemia Arteriosclerosis Arthritis Asthma Autoimmune disorder Bleeds easily Blood pressure - high Blood pressure - low Bruises easily Cancer Chemotherapy Chronic fatigue Chronic pain COPD Current pregnancy Dizziness Emphysema Epilepsy Fibromyalgia Glaucoma Gout Heart attack Heart disorder Heart murmur Heart pacemaker Heart valve replacement Hemophilia Hepatitis Hypertension Hypoglycemia Immune system disorder

3 Depression Kidney problems Diabetes Liver disease Significant Current Date/Note Significant Current Date/Note Medical Condition Never Past Medical Condition Never Past Difficulty sleeping Meniere s disease Mitral valve prolapse Rheumatoid arthritis Sinus problems Sleep apnea Multiple sclerosis Muscular dystrophy Nasal allergies Neuralgia Osteoarthritis Osteoporosis Parkinson s disease Psychiatric care Radiation treatment Rheumatic fever Stroke Tendency for ear infections Thyroid disorder Tuberculosis Tumors Urinary disorders Prior orthodontic treatment Surgical Operations Appendectomy Heart Thyroid Back Hernia Repair Tonsillectomy Ear Lung Uvulectomy Gallbladder Nasal Periodontal Family History Has any member of your family (parent, sibling, or grandparent) had: Cancer Stroke Father snores Heart disease Sleep disorder Mother snores Diabetes Obesity Father has sleep apnea High blood pressure Thyroid disorder Mother has sleep apnea Social History Patient s Occupation: Employer: Tobacco Use: Cigarettes Never smoked Current smoker Quit # of packs per day: When did you quit? Other tobacco: Pipe Snuff Cigar Chew # of years: Alcohol Use: Do you drink alcohol? Yes No If yes, # of drinks per week: Caffeine Intake: None Coffee/Tea/Soda # of cups per day: Additional: Regular Exercise I authorize the release of a full report of examination findings, diagnosis, treatment program, etc. to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.

4 I certify that the medical history information is complete and accurate. Sleep Consultation Patient Name: DOB: / / Current Date: / / Referring Physician: City, State, Zip Code: Chief Complaints 1. Please number your complaints with #1 being the most severe, #2 the next most severe, etc. 2. Then rate your complaints for frequency and intensity. a. Frequency: 1- seldom, 2- occasional, 3- frequent, 4- every day b. Intensity: 0- no pain through 10- most severe pain Number Frequency Intensity Number Frequency Intensity CPAP Intolerance Nighttime choking spells Difficult falling asleep Fatigue Significant daytime drowsiness Sleepiness while driving Frequent heavy snoring Witnessed apneic events Frequent heavy snoring which affects the sleep of others Morning hoarseness Gasping when waking up Morning headaches Epworth Sleep Scale Questionnaire How likely are you to doze off or fall asleep in the following situations? Check one in each row: No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and reading Watching TV

5 Sitting inactive in a public place (e.g. a theater or a 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 a lunch without alcohol In a car, while stopped for a few minutes in traffic CPAP Intolerance (Continuous Positive Airway Pressure Device) Total Score: (Add Columns 1 3) If you have attempted treatment with a CPAP device, but could not tolerate it please fill in this section: Mask leaks CPAP restricted movements during sleep An unconscious need to remove the CPAP Inability to get the mask to fit CPAP does not seem to be effective Does not resolve symptoms properly Discomfort from headgear Pressure on the upper lip causing Noisy tooth- related problems Disturbed or interrupted sleep Latex allergy Cumbersome Noise disturbing sleep and/or bed partner s sleep Claustrophobic associations Sleep Studies If you have had a Sleep Study, please check one of the following: Home Sleep Study Polysomnographic evaluation at a sleep disorder center Sleep Center Name: Sleep Study Date: For Office Use Only The evaluation confirmed a diagnosis of: an RDI of: The evaluation showed: During REM Supine Side

6 an AHI of: a nadir SpO 2 of: T90 ODI (Oxygen Desaturation Index) Slow Wave Sleep Decreased None REM Sleep Decreased None Other Therapy Attempts Dieting Weight loss Surgery (Uvuloplasty) Surgery (Uvulectomy) Pillar procedure Smoking cessation CPAP Bipap Uvulectomy (but continues to have symptoms) Uvuloplasty (but continues to have symptoms) History of Treatment Practitioner s Name Specialty Treatment Approximate Date Sleep History Previous Diagnosis: Have you been previously diagnosed with Obstructive Sleep Apnea? Yes No o If yes, how long ago was it? Years ago Months ago Days ago

7 Sleep: Sleep Onset Latency: (minutes) Normally goes to bed at: AM PM Hours of sleep per night: Do you use a sleep aid? Yes No If yes, name the medication and dosage: Wake: Sleepiness while driving? Yes No Risks discussed Yes No The patient: Awakens unrefreshed Has morning headaches Naps: Naps daily Never naps Occasionally naps Bruxism Dry mouth Excessive movements Gasping I awaken number of times per night Hypnagogic Hallucinations Restless legs Waking up and having difficulty returning to sleep Dreaming Frequency of nocturnal urination (# of times) Snoring is reported as: Frequency: Nightly Seldom Never Severity: Light Moderate Loud Often Witnessed apneas are: Worse during supine sleep Worse following alcohol late at night Worse during supine sleep Worse following alcohol late at night