SLEEP STUDY INFORMATION
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- Camilla Dalton
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1 Consultants in Neurology Rowe Neurology Institute or Marshall Drive 5500 N Oak Trafficway Suite 100 Suite 203 Lenexa, Kansas Kansas City, MO xt xt 218 SLEEP STUDY INFORMATION Your scheduled appointment time and date is: : PM on ****ARRIVE ON TIME and NOT EARLY for your scheduled Sleep Study***** The building is locked for your security during the evening hours. At the main entrance, we have an intercom and a video camera. Press the intercom button, which alerts the sleep technician. They will then come and escort you to the sleep lab for your testing. Please be patient. The technician may be with another patient. WHAT TO BRING: You will have time to change into nightclothes and get ready for bed, as you do at home. If you are male, you must wear running shorts, sweat pants, or pajama bottoms. You may wear a shirt if you like, but it is not necessary. If you are female, you may wear a night gown, a large shirt, or pajamas. Please feel free to bring your favorite pillow from home however, electric blankets are prohibited. You may also want to bring an overnight bag, as you would for an overnight stay at a hotel. Flat Screen Satellite TV s are available for your comfort; you may also want to bring reading materials, or something to work on before Lights Out. WHAT HAPPENS DURING THE STUDY: During preparation for sleep monitoring, various small sensors will be applied to the scalp, face, chest, and legs. These monitoring devices are not painful and are designed to be as comfortable as possible while you sleep. Please avoid using hair spray, lotions, face creams or makeup prior to the test. Male patients not having beards should be clean-shaven. The study will be recorded digitally for later review of abnormalities observed during the study. The technician will monitor your sleep throughout the night from a nearby room. Please remove any hair weaves, braids, or bonds prior to testing. Also, during your study you will likely be asked to remove your watch. There will be a photo taken of you prior to testing. WHAT HAPPENS FOLLOWING THE STUDY: The sleep study and its analysis and interpretation are part of a complex process. Many hours of work are required by a trained sleep technologist, who processes or scores the large amount of data recorded during the study. The information is then interpreted by a sleep specialist with special knowledge of sleep and its disorders. Because this is a time-consuming process, results may take several weeks to be evaluated. You will be contacted as soon as your results are ready. K:\ Handouts\Sleep\RNI NEW SLEEP DISORDERS CENTER INFO.doc
2 PLEASE REVIEW THE DAY OF YOUR STUDY: DO NOT take naps during the day of your study. DO NOT eat a large or spicy meal immediately before coming in for your study. DO NOT eat or drink any food with caffeine such as COFFEE, TEA, SODAS, OR CHOCOLATE, after 3pm before your study. DO NOT drink alcoholic beverages on the same evening of the study. BEFORE coming to the sleep center, wash and dry your hair, and do not apply hair sprays, oils, gels, lotion or night creams. Men, not having beards, please come clean-shaven. You will probably want to take a bath or shower prior to coming in. Also, no fingernail polish, weaves, or extensions. TAKE your medications as usual, or as your doctor recommended. Bring current list of your medications. PLEASE bring comfortable sleep attire and toiletries. PLEASE have this packet of paperwork completed upon arrival for your study. If you need to contact someone or leave a message for the sleep center in the evening (after 4:30 PM), Please call (913) Lenexa Location ext 161 or Kansas City (Creekwood) Location ext 218. You will be contacted with the results of your sleep study according to the option selected on your Authorization To Disclose Sleep Study Results. If I must cancel my Sleep Study and/or PAP titration appointment(s), I understand that it is my responsibility to cancel by phone A MINIMUM OF ONE BUSINESS DAY 24 hours in advance meaning MON FRI. Failure to cancel will result in a $ fee. X Signature Signed in the New Paperwork Date If you need to Re-Schedule or cancel your appointment, please call the scheduling team at: (913) between 8:00 AM and 4:00 PM Monday Friday. Thank you for your cooperation, The Sleep Team K:\ Handouts\Sleep\RNI NEW SLEEP DISORDERS CENTER INFO.doc
3 Name: ID Number: Date Completed: Height: Weight: LIST ALL CURRENT MEDICATIONS INCLUDING VITAMINS AND HERBAL SUPPLMENTS Have you recently started or stopped any prescribed medications? If so, state the name of the medication, if it was added or stopped, and the date you began or ended it. PLEASE CHECK ANY OF THESE THAT APPLY: Snoring Snorting/Gasping SN SNT Fatigue FTG Excessive Daytime Sleepiness Chronic Pain EDS CP Stress STR Leg Jerking Morning Headache Migraine LJ MH MIG Loss of Muscle Tone Acid Reflux / GERD Teeth Grinding LMT ACR TGR Panic Attacks Depression Anxiety PA DEP ANX Difficulty Falling Asleep Difficulty Staying Asleep Acting Out Dreams DSI DSM RBD Hallucinations Sleep Attacks Sleep Talking HLC SAT SLT Sleep Walking Sleep Eating Wake Up Too Early SWK SE EAW Poor Memory Frequent Nocturnal Urination Frequent Awakenings PM FNU FAW Poor Concentration High Cholesterol Night Sweats PC HCH NST High Blood Pressure/Hypertension Non-restorative Sleep Legs Sore and Achy HYP NSR RLS Claustrophobia History of Seizures or Spells Briefly Can't Move Upon Waking CL HXSZ SP Heart Attack Stroke Peripheral Vascular Disease Legs Moving Restlessly HXHA HXST PVD RLSC Witnessed Breathing Issues During Sleep Do you have any other medical conditions WA which we have not listed? Frequent Body Position Changes Coronary Artery Disease FBPOS CAD Heart Failure HF Cardiovascular Disease CD Heart Problems HP Diabetes? Type: Controlled? DBT Page 1 of 4
4 SLEEP HABITS Understanding your normal sleep habits is important in understanding more about your sleep or sleep problems. Do you work swing shifts or night shifts? Yes No What is your normal bed time? On average, how many minutes does it take you to fall asleep? Do you go to sleep with the television on? Yes No What is your normal wake time? Do you frequently hit the snooze button in the morning? Yes No How long does it take you to wake up in the morning? How long do you sleep on a normal night? Do you fall asleep at work or school? Yes No Have you ever fallen asleep while driving? Yes No (Please remember, NEVER drive while drowsy/sleepy!) What time did you go to bed last night? What time did you wake up? Approximately how many hours of sleep do you think you got last night compared to time spent in bed? Over the past couple of weeks, how many hours per night did you sleep? Do you use oxygen? Yes No If yes, do you use oxygen: All the time. Night Time LPM: Page 2 of 4
5 Do you currently wear Positive Airway Pressure therapy (CPAP, BIPAP, or Auto SV) while you sleep? Yes NO If so, what is your current pressure setting? cm H2O Who is your Current Durable Medical Equipment (DME) Provider? How many hours per night do you wear your CPAP/BIPAP/Auto SV? How long have you been on positive airway pressure therapy? Does anyone in your family have a known sleep disorder; tell us which sleep disorder and how they are related to you: PLEASE TELL US ABOUT YOUR DAY TODAY HAVE YOU HAD ANY OF THE FOLLOWING TODAY? IF SO, WHEN AND HOW MUCH: Caffeine: Alcohol: Nicotine: Other: Do you use or have you used during the past week, any recreational street drugs? Was your last meal heavy, or light? What time was that? Was your day today unusually exciting or stressful? If so, how? Do you have any physical complaints at this time such as pain, cold/hot, aches, etc.? Are you tired / sleepy now? If not, why? Do you have any additional comments or concerns? Page 3 of 4
6 Epworth Sleepiness Scale Please use the following scale, to decide the likeliness you would doze off or fall asleep in the following situations. Even if you have NOT done some of these things RECENTLY, try to answer how they would have affected you. Using the following scale, Please choose the most appropriate number for each situation: 0 = Would NEVER doze or fall asleep, 1 = Slight Chance of dozing or falling asleep, 2 = Moderate Chance of dozing or falling asleep, 3 = High Chance of dozing or falling asleep Chance of Situation: Dozing: Sitting and Reading Watching TV Sitting, Inactive in a public place (Theatre, meeting, etc.) As a 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, without alcohol In a car while stopped for a few minutes in traffic TOTAL SCORE Add up the numbers you put in each box to get your total score. A total score of less than 10 suggest that you may not be suffering from excessive daytime sleepiness. A total score of 10 or more suggests that you may need further evaluation by a physician to determine the cause of your excessive daytime sleepiness and whether you have an underlying sleep disorder. It is important to remember that true excessive daytime sleepiness is almost always caused by an underlying medical condition that can be easily diagnosed and effectively treated. PATIENT SIGNATURE: SLEEP TECH SIGNATURE: Date: Date: Page 4 of 4
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Psychological Sleep Services Sleep Assessment
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Instructions. 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
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St. Louis Heart and Vascular - McKelvey Office May 28, 2018 (Page 1) Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. Today s Date: My Main
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Welcome to the UCLA Sleep Disorders Center Our Sleep Center Website is:
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Do You Snore? Are you always tired? Snoring is no laughing matter! It may be more than an annoying habit. It may be a sign of. How well do you sleep? Just about everyone snores occasionally. Even a baby
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Tallahassee Memorial Sleep Center Patient Questionnaire
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28533 Spring Trails Ridge #220 Spring, TX (832) Office (832) Fax
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Please 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
Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
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