493 Blackwell Road, Suite 317-A, Warrenton, VA
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1 493 Blackwell Road, Suite 317-A, Warrenton, VA 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 possible to: Fauquier Health Sleep Diagnostic Center 493 Blackwell Road Suite 317-A Warrenton, VA Fax Number (540) Please include a copy (front and back) of your insurance cards and photo ID along with the physician s order. Once we receive the completed packet, we will contact you to schedule your sleep study. Thank you for your assistance in expediting this process. If you have any questions, please contact me at (540) , Monday through Friday between 9 a.m. 4 p.m. Sincerely, Victoria Earhart Patient Care Coordinator
2 EPWORTH SLEEPINESS SCALE (ESS) This questionnaire will help you measure your general level of daytime sleepiness. Rate the chance that you would doze off or fall asleep during different routine daytime situations. Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3: with 0 meaning you would never doze or fall asleep in a given situation; and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation. How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven t done some of the activities recently, think about how they would have affected you. Use this scale to choose the most appropriate number for each situation: 0 = would never doze 2 = moderate chance of dozing 1 = slight chance of dozing 3 = high chance of dozing It is important that you circle a number (0 to 3) for EACH situation. SITUATION CHANCE OF DOZING Sitting and Reading Watching Television Sitting inactive in a public place (theater/meeting) 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 (with no alcohol) In a car, while stopped in traffic TOTAL SCORE
3 Name: Date: Patient s Name: Date of Birth: Home Address: Street City State Zip Code Home Phone: ( ) Work Phone: : ( ) Sex: M / F Age: Height: Weight: lbs. Neck Size: Y N Comments Do you snore? O O Does your Bed-partner say you snore: O O Do you stop breathing while you re asleep? O O Do you have a bed-partner who say you stop breathing? O O Are you sleepy during the day? O O Do you wake up with a headache? O O Do you Nap during the day? O O Any problems with sleepiness while driving? O O Do your legs move a lot when you sleep? O O Does your Bed-partner say your legs move: O O Do you act out while dreaming? O O Does your Bed-partner say you act out while dreaming: O O Have you ever had a prior sleep study? If so, where and when did you have it? Do you wear oxygen when you sleep? If yes, at what setting? What time do you go to bed? Do you have any medical conditions? Do you wear a CPAP/BIPAP If yes, at what setting? What time do you normally wake up? If yes, please list them: Do you take any medications? If yes, please list them with the dosage: Fauquier Health Sleep Center 493 Blackwell Road Suite 317-A, Warrenton, Virginia Telephone # / Fax #
4 Who is the physician ordering the Sleep Study? Physician s address Physician s phone number Demographic Information Patient s name: Date of Birth: Last First MI Home Address: Street City State Zip Code Home Phone: ( ) Work Phone: ( ) Social Security #: Marital Status: Married Single Divorced Separated Life Partner Place of Employment: Occupation: Sex: Age: Height: Weight: lbs. In case of an emergency, please contact: Name Relationship Phone # Insurance Information Policy Holder/Guarantor Information (if different from the patient): Name: Social Security #: Relationship to patient: Date of Birth: Place of Employment: Primary Insurance: Phone #: Policy/Member #: Group #: Claims Address: Name of Policy Holder: Relationship: Secondary Insurance: Phone #: Policy/Member #: Group #: Claims Address: Name of Policy Holder: Relationship:
5
Sleep 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
PATIENTS 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
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE
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Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
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What s the name of your position?
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Emergency 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:
Baptist 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
Patient 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:
Denver, 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,
Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
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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
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Occupation: 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
Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
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The following questions are about your sleep. Please consider both what others have told you about your sleep and what you know yourself.
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PATIENT 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:
General Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
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PATIENT DEMOGRAPHICS
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
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PATIENT AUTHORIZATION TO RELEASE MEDICAL RECORDS AND DEMOGRAPHIC INFORMATION DATE: SS #: PATIENT NAME: BIRTHDATE: / / PATIENT ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE #: CELL PHONE #: REFERRING PHYSICIAN
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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
Sleep 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
Patient Medical History
Date: The PMA Metabolic and Bariatric Weight Management Center 410 West Linfield-Trappe Road, Suite 100 Limerick, PA 19468 (610) 495-2338 Patient Medical History Name: Date of Birth: Age: Female Male ALLERGIES:
The Medical Center Sleep Center
The Medical Center Sleep Center Date: / / Name: Age: (First) (M.I.) (Last) Address: (Street / P.O. Box) (City) (State) (Zip) (County) Phone: Home ( ) Work ( ) Date of Birth: / / Education: Marital Status:
Section 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