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.

Transcription

1 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 has been scheduled for: at PM The day of your Sleep Study Wash your face and hair to remove make-up, oils, and styling products. You must bring loose sleepwear to allow for equipment set-up. You may bring your own pillow and or blanket if you wish. Otherwise they will be provided. Do not drink alcohol. Do not eat or drink food or beverages that contain caffeine (including coffee, chocolate, cola, tea, etc.) after 12 Noon. Eat as you normally would prior to your arrival, as no food may be consumed in the Sleep Center. Avoid napping. Bring all medications you take between the hours of 9:00pm and 6:00am. Inform the technician if you use supplemental oxygen. Bring this questionnaire, completed to the best of your ability. To better aid us in evaluating your symptoms and identifying their causes, we ask that you fill out the enclosed questionnaire and bring it with you when you come for the Sleep Study. NO family members may stay with patients for setup or overnight testing. Due to the length and nature of the study, lights will be turned off no later than 11:00pm. NO reading or television after lights are turned out. If this date and/or time is inconvenient for you or you have any questions regarding your study, please do not hesitate to call our office at (813) We require a 48-hour notice in the event you need to cancel or reschedule your study. We also reserve the right to charge $ for any missed appointments if a 48-hour notice is not given. Our office hours are 8:00am to 4:30pm Monday through Friday. After you receive your Sleep Study appointment, be sure to schedule a follow up appointment 2-3 weeks after your study. Sincerely, The Doctors and Staff at Tampa Bay Sleep Center

2 Please provide us with the following information: Page 2 Date: Name: SSN: Address: Birth Date: Age: Race: Marital Status: Occupation: Weight: Height: Collar Size: Who referred you to the Sleep Center? Who is your Family Physician? What is your main sleep problem? When did this problem begin? Is your problem: Increasing Decreasing Remaining the Same Do you snore when you sleep? Yes No If you snore, please circle in which All Positions Back Sides Stomach position: Has anyone ever told you that you stop breathing at night? Yes No Current Medical Information: Are you currently receiving any medical treatment? Yes No If yes, please provide the following information: Current Illness (i.e. high blood pressure, diabetes, heart problems, thyroid, depression, etc.) Current Medications (please list dose also)

3 Page 3 Daytime Functioning: Do you feel FATIGUE (tiredness, exhaustion, lethargy) in the daytime even when not sleepy? No Infrequently Occasionally Often Always Do you feel SLEEPY (or struggle to stay awake) in the daytime? No Infrequently Occasionally Often Always If so, under what circumstances do you fall asleep easily? Driving After Meals Meetings, class, church On the Telephone Watching TV, reading Other Have you had a car accident or near miss because of falling asleep driving? Yes No If yes, were you sleeping well before the incident, or had you been keeping late hours, etc.? Do you fall asleep during the day enough to interfere with your: Household chores Marriage/Relationships Job Performance School Work How often do you feel alert and energetic for an entire day? Never Upon Occasion Most of the Time All of the Time Do you take naps (intentional and/or unintentional) during the day? Yes No If yes, please list the time and frequency below. Do you feel refreshed after your naps? Yes No Do any of your sleep problems seem to go in cycles or recur at regular intervals? Yes No If yes, describe the cycle.

4 On a scale of 1 to 5 how well do you function in the: Page 4 Worst Best Morning Midday Afternoon Late Afternoon Evening Mood: Has your memory been getting worse lately? Yes No Have you had difficulty concentrating lately? Yes No Have you been feeling more irritable lately? Yes No Have you ever been treated for depression, anxiety or severe stress? Yes No If yes, what were the circumstances and how were you treated? How much stress would you say you were under right now? If you are under tress, is it related to: Work Personal life Other Have you been feeling more depressed lately? Have you been feeling Hopeless Helpless Worthless Useless Have you seriously thought about suicide recently? How is your appetite? How much weight have you: Lost or Gained in the past year?

5 Current Sleep Habits: Page 5 Do you sleep alone? Yes No If no, who sleeps in bed with you? Spouse Significant Other Child/Parent Do you have any pets that sleep in bed with you? Yes No Do you consider yourself to be a: Very good sleeper Moderately poor sleeper Moderately good sleeper Very poor sleeper Do you consider your bed partner to be a: Very good sleeper Moderately poor sleeper Moderately good sleeper Very poor sleeper How regular are your sleep habits? Very regular Usually quite regular Usually quite irregular Very irregular Weekdays, what time do you usually go to bed? Does this vary by: Mins or Hours Weekdays, what time do you get up in the morning? Does this vary by: Mins or Hours Approximately how long does it take you to fall asleep after turning out the lights? When you wake up during the night, how difficult is it for you to go back to sleep? If you can t sleep, do you get out of bed? Yes No Do you watch television to help you sleep? Yes No How many times do you wake up at night on average? How many hours do you feel you actually sleep on weeknights? Do you keep the same sleep schedule on weekends or your days off? Yes No If not, what is your bedtime on weekends or your days off? Waking time Do you feel better on weekends? Yes No How often do you get up at night to provide care for someone (child, spouse)? How often is your sleep disturbed because of pain or discomfort?

6 Describe your normal workdays and hours: Page 6 If you do shift work, how often does your shift change? In general, what effect does shift work have on your sleep complaint? Worsening Slight Worsening Much Improvement Slight Improvement No Effect How do you feel when you wake up to start your day? Alert, Awake Energetic Refreshed Anxious Drowsy, Sleepy Low Energy Confused Depressed Before you are fully asleep do you have very vivid, frightening, hallucination like dreams? Yes No Have you ever awakened from sleep and found that your body felt paralyzed and you couldn t move at all, even though you could breathe and see? Yes No Do you have difficulty falling asleep because your legs are restless or have crawling sensation? Yes No Family Sleep History: Has any member of your family been diagnosed with a sleep problem? Yes No If so, what was the diagnosis and what is their relation to you? Has any member of your family died in their sleep? Yes No Childhood Sleep History: Please circle any of the following sleep behaviors that occurred when you were a child or an adolescent. Sleep walking Sleep talking Bed wetting Twitching or jerking Night terrors/ Screams Snoring/ Asthma Grinding teeth Excessive sleepiness in school Seizures in sleep Insomnia Inability to sleep until very late at night Head banging

7 Page 7 In response to intense emotion (laughter, anger, surprise) have you felt sudden muscle weakness in your legs, neck, or other extremities? (This does not refer to known muscle or joint problems, or to lightheadedness.) Yes No Please describe the emotions involved and what muscles went limp. During your sleep, do you currently (in the past six months) have problems with the following: Symptom Always Most of the Time Occasionally Never Choking/ gasping Shortness of breath Chest pains Heart palpitations Night sweats Increased urination Tossing and turning Leg or body jerks Grinding teeth Sleep walking Shouting/ nightmares Falling out of bed Back pains while asleep Heartburn/ gas pains Anxiety/ panic attacks Cold feet at night Morning headaches Dry mouth in morning Any other unusual behavior: Who should we contact in case of an emergency? Name: : Telephone: : Relationship: Is there anything else that you feel is important about your sleep, medical or psychological history that we may not have covered? Please use the back of this page to explain.