VERY IMPORTANT INFORMATION
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1 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 enclosed letter for registration. Complete the forms in this packet and bring them with you the night of your study or the day or your HST pick-up. If you need to take any medications before bedtime, bring them with you (this includes something as basic as aspirin or Tylenol). Medications CANNOT be provided to you by the sleep center. In-lab patients must have your hair clean and dry the day of your test. Do not wear makeup or use any products in your hair. Do not apply any heavy creams or lotions to your skin because they alter the quality of your test. Bring something to sleep in that is 2-piece and loose-fitting if you are an in-lab study. ALL patients: Bring your insurance card and a photo ID (driver s license) Go about your normal day; this includes performing all your usual activities and taking all of your usual medications. Try to avoid: o Naps unless they are a usual part of your day. If you do nap, make it slightly shorter than usual. o Excessive amounts of caffeine, more than normal (coffee, tea or cola beverages). If you have special needs (i.e. hospital bed, bedside commode, oxygen, nebulizer, etc.) and you have not already advised your scheduler, call prior to your appointment (Mon Fri, between the hours of 8:00 am 7 pm). In some cases, it may be necessary for you to bring your equipment from home. If you have not yet spoken to the pre-registration department, call the number listed on the letter at the front of this packet for pre-registration.
2 Common Questions Regarding Sleep Testing What symptoms might lead my doctor to suspect I have a sleep disorder? Some symptoms include excessive daytime sleepiness, fatigue, depression, insomnia, hypertension, morning headaches, poor concentration and memory loss. Perhaps your bed partner has complaints of loud snoring/snorting, teeth grinding, active leg/body movements during sleep and many others. What is a sleep test? The technician assigned to you will apply various monitors to your head, chest, legs, finger, nose, mouth and throat. These specialized devices will record the details of your sleep and tell the doctor about the quality of sleep you are getting, oxygen level, heart rhythm, breathing pattern and other things occurring while you sleep. What is an HST? The HST is a Home Sleep Test based upon your medical history and symptoms it may be determined that this test is more suitable for you. The HST monitors respiratory, effort, snore, oxygen and pulse. HST is used to determine whether or not a patient has sleep apnea. How long does this test take? In-lab: In order to obtain an accurate account of all the complicated functions of sleep, you are expected to stay for six to eight hours the night of your test. It will take the technician approximately 45 minutes to apply the recording devices and approximately 15 minutes to calibrate the devices to you. During the calibration, you will follow verbal commands given by the technician. HST: The HST is started by the patient at the patients' natural sleep time and ended at their natural wake time. The device has an average battery life of 10 hours What if I need something or have to go to the restroom in the middle of the night? Once you are connected to the testing equipment, you can move freely in bed. If you need to leave the bed for any reason, state your request out loud and a technician will be there promptly to assist you. What is CPAP? What does CPAP do? CPAP stands for Continuous Positive Airway Pressure. It is a small bedside unit that has tubing and a small mask that is placed gently over your nose and delivers air into your airway. It assists your body in breathing while allowing you to rest so that breathing irregularity does not keep you from sleeping properly. If the technician observes a breathing problem during your study, he/she may awaken you to continue the test with one of these devices. Will there be TV in the room? Each room has a TV however; at some point in the evening the technician will ask that you attempt to fall asleep without the TV on for clinical reasons. Will I have to pay for parking? No, there is free parking at the hospital. Please use the ER Entrance and there you will be registered for your sleep study before being taken to the Sleep Lab. Will I be able to have a family member stay with me? No, we do not have additional rooms for family to stay. If a caregiver is required, the caregiver is to stay in the room monitoring the patient. PLEASE DO NOT ARRIVE MORE THAN 15 MINUTES PRIOR TO YOUR APPOINTMENT TIME
3 Name: DOB: Today s Date: Height: ft in Weight: lbs Neck Circumference: in (staff can measure if unsure) A) CHIEF COMPLAINT Describe your sleep/wake problems and how long it has been present: B) TYPICAL SLEEP TIMES What time do you go to bed? Weekdays: Weekends: What time do you get out of bed? Weekdays: Weekends: How long do you nap during the day? Weekdays: Weekends: How much time do you spend asleep? Weekdays: Weekends: How many times do you awaken from sleep each night on average? What do you think causes this or what do you notice at that moment? C) PAST MEDICAL HISTORY Check all that apply: Hypertension Asthma Congestive Heart Failure Chronic Obstructive Pulmonary Disease Heart Attack Diabetes Coronary Artery Disease Stroke/Transient Ischemic Attack Impotence Depression Home Oxygen Hypothyroidism Emphysema Epilepsy/Seizure - Date of most recent seizure: D) CURRENT MEDICATIONS List all prescription and non-prescription medications. Use space below if necessary. Name of Medication Dose Times a Day ALLERGIES: ⶸ ⶺ 1/12/17 Page 1 of 5
4 E) PAIN Are you currently having any pain? Yes No If yes, please describe the pain below. Origin: Onset: Location: Quality (i.e. burning, dull ache): Intensity: Rate on a scale of 0-10 (0 = no pain and 10 = unbearable) Frequency/Duration: Aggravating/Relieving Factors: Pain Management History: Present Pain Management Regimen and Effectiveness: F) FAMILY SLEEP HISTORY Do any of your relatives have a sleep disorder? Yes No Check all family members that apply: Mother Father Brother Sister Son Daughter Check the type of sleep disorder(s): Sleep apnea Narcolepsy Restless legs Insomnia Other G) SOCIAL HISTORY Complete the following general information. Check Appropriate: Live and sleep alone Someone sleeps in a room nearby Have roommate Married What is your occupation? Number of caffeinated drinks per day: Number of tobacco products per day: Number of alcoholic drinks per week: Number of years smoking: H) REVIEW OF SYSTEMS Please check those issues that apply to you. Ear, nose, mouth, throat: Frequent sore throat Hay fever/allergies Sinus trouble Tonsillectomy TMJ Syndrome Respiratory symptoms: Shortness of breath w/exertion Asthma / Emphysema Chronic cough Neurological problems: Stroke or TIA Seizure Neuropathy Major head injury Kidney problems: Known kidney disease Kidney stones Prostate problems Psychiatric issues: Depression Chronic Anxiety Panic attacks Cardiovascular symptoms: Recurrent Chest pain Palpitations or arrhythmia High Blood Pressure History of MI / heart attack Congestive Heart Failure (CHF) Gastrointestinal symptoms: Heartburn/GERD Mononucleosis or liver disease Musculoskeletal problems: Neck or back problems Arthritis Endocrine or gland problems: Thyroid disorder Heat or cold intolerance Diabetes Constitutional symptoms or issues: Poor appetite Weight gain over past two years How Much? lbs 1/12/17 Page 2 of 5
5 I) SLEEP COMPLAINTS/PROBLEMS - Circle the number for each complaint/problem listed using the scale below. SCALE: 0 = Never 1 = Rarely 2 = Sometimes 3 = Often 4 = Very Often 5 = Always The following list includes possible complaints or problems associated with sleep at night Snoring disturbs others Gasp or wake up from sleeping choking Stop breathing for short periods Feel paralyzed when falling asleep or waking up Have near hallucinations or dreamlike images when falling asleep or just waking up Have leg cramps at night Uncomfortable, crawling sensation in legs that is relieved by moving or walking Jerk your arms or legs at night Sleep restlessly Have aches or pains at night describe: Have problems falling asleep at night or staying asleep Lie away feeling depressed, worried or anxious Grind you teeth at night Frightening dreams or nightmares Walk in sleep Talk in sleep Sleep often disturbed by your partner Sleep often disturbed by noise or pets Smoke at night Eat in bed at night Watch TV in bed Wake up with nausea or heartburn Wake up with chest pain The following list includes possible DAYTIME complaints or problems associated with sleep Feel unrefreshed in the morning after sleep Find it hard to wake up in the morning Irritable Unable to concentrate Poor memory during the day Yawn frequently during the daytime Feel drowsy or sleepy during the day Daytime sleepiness interferes with normal activities Daytime fatigue Have hallucinations or dream-like mental images during the day Have sudden physical weakness or paralysis when laughing, angry or other emotional situations Have daytime sleep complaints that seem to go in cycles or only appear at certain times (example: only in evenings; every 10 days; when you sleep away from home) 1/12/17 Page 3 of 5
6 J) EPWORTH SLEEPINESS SCALE Using the scale below, indicate the likelihood you would fall asleep in the following situations. The 0-3 scale refers to your usual way of life in recent times. 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Sitting and reading. Sitting quietly after lunch. Watching TV. As a passenger in a car for an hour without a break. In a car, while stopped for a few minutes in traffic. Sitting and talking to someone. Lying down to rest in the afternoon. Sitting, inactive in public place (i.e. theater or a meeting) TOTAL SCORE K) CLAUSTROPHOBIA Do you experience claustrophobia (fear of being enclosed in a small space or room)? No Yes If yes, how would you rate the symptoms: Mild Moderate Severe Signature: Date/ Time: If there are other physicians you would like to receive a copy of the test results, please list their names, phone numbers and addresses here: 1/12/17 Page 4 of 5
7 / Sleep Log Instructions: 1. Leave the times you are awake BLANK. 4. Put an ARROW UP ( ) whenever you awaken, including naps. 2. SHADE, crosshatch, or color in the times when you sleep. 5. Put M for meals, S for snacks, and D for alcoholic drinks. 3. Put an ARROW DOWN ( ) whenever you lie down to sleep. 6. Include notes below each week or on the back. EXAMPLE: Noon Midnight DATE: 6 A P A M D S S FIRST WEEK: Noon Midnight DATE: 6 A P A SECOND WEEK: Noon Midnight DATE: 6 A P A Page 5 of 5
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Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
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
Brunswick 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
New Sleep Patient Questionnaire. Name Age Date. General Medical History 1. Please list any surgeries you have had and their approximate dates:
1 John S. Kim, M.D., Diplomate ABSM Lawrence A. Lynn, D.O., FCCP 1251Dublin Rd. Columbus, Ohio 43215 (614) 297-7704 (614) 297-7705 New Sleep Patient Questionnaire Name _ Age Date General Medical History
PATIENT INFO SLEEP VISIT
Pulmonary Associates of LVPG A practice of Lehigh Valley Physician Group 1250 S. Cedar Crest Blvd., Suite 205, Allentown, PA 18103 1770 Bathgate Drive, Suite 403, Bethlehem, PA 18017 610-439-8856 (phone)
BMI: 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
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:
Pre-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
PEDIATRIC 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
Sleep 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
Patient Adult Information History
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
Height: 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
Date 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
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE Please answer each question accurately and to the best of your knowledge, to help us obtain an accurate picture of your health and sleep issues, only this way will we be able
YOUR 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
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
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
Sleep 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
GARY POLK, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT
GARY POLK, M.D. PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Pharmacy/Location Date: Age: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3) YOUR PAST MEDICAL HISTORY
SLEEP STUDY CANCELLATION/ NO SHOW POLICY
Olusegun Oseni, MD F.C.C.P. 945 Hilltop Dr, Ste 101 Weatherford, Texas 76068 Phone: 817-594-9993 Fax: 817-594-9915 SLEEP STUDY CANCELLATION/ NO SHOW POLICY Dear Patient: We understand that emergencies
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
SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE Please bring this completed questionnaire with you to your sleep clinic appointment.
SLEEP DISORDERS CENTER Please bring this completed questionnaire with you to your sleep clinic appointment. Patient s Name: Date: Referring Physician: Clinic Location: Primary Care Provider: Clinic Location:
Kelowna Sleep Clinic Dr. Ronald Cridland Inc Sleep Questionnaire
Dr. Ronald Cridland Inc Sleep Questionnaire Name: Date: d/m/yr Date of Birth: d/m/yr Age: Marital Status: Sex: M F Address: City: Province: Postal Code: Health Care #: Home Phone #: Work Phone #: _ Cell