Humble Dreams Sleep Center. Humble, TX 77339
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- Jemimah Floyd
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1 Humble Dreams Sleep Center 8901 FM 1960 Bypass West, Ste. 306 Humble, TX Dear Humble Dreams Sleep Study Patient, Thank you for allowing Humble Dreams Sleep Center to provide your sleep study as requested by your physician. Included with this document are a few questionnaires as well as a list of the do s and don ts pertaining to the sleep study. Also included is a map of our location. You should plan on arriving for your study at 8:30pm. Your study will last until 6:00am the following morning, unless specifically requested otherwise. If you have any questions about the instructions, information or questionnaires, please don t hesitate to call us. We look forward to seeing you soon and to beginning the process that will lead to the successful correction of your sleep disorder. Sincerely, Darrell Henry Director of Operations
2 THE DAY OF TESTING: DO NOTS: Please do not take any naps. Please do not drink caffeinated beverages after 4:00 p.m. Please do not sleep past 9:00 a.m. on the day of your test. DO S: Eat dinner before reporting. Bring a list of all your medications. Continue to take all your medications according to your doctor s instructions. Bring any medications that you will need to take between the hours of 7:30 p.m. and 7:30 a.m. Bring your own sleepwear (No silk clothing). You may bring your own pillow if you wish. Plan for comfort. PREPARATION FOR TESTING: Please wash your hair the night before or the morning of your study and avoid using hair products the day of the study. If this is not practical, please wash your hair when you arrive. Please arrive without make- up, if possible. If this is not practical, please wash your face to remove make- up when you arrive. Unless you have a beard, please be clean- shaven. If you have a beard, we can work around it, but beard stubble is very difficult to work with. Hairpieces and wigs must be removed. We must be able to get to your scalp to do the test. GOING HOME: You will be awakened at 6:00 a.m. the next morning and you may leave as soon as you are ready to go. Checkout time is at 7:30 a.m. at the latest. GUESTS: Adult family members are welcome and encouraged to be present for the educational portion of the study. However, we do discourage anyone from staying over- night unless scheduled for a study. If you require the help of a personal care assistant due to a medical disability, we are be happy to have your PCA stay with you. If you feel it is necessary to have someone stay with you, please call us at (281)
3 IF YOU NEED TO RESCHEDULE OR CANCEL YOUR STUDY: WHEN: If you need to cancel or reschedule your appointment please call us at (281) You may leave a message on voic if outside of normal business hours. If you do not show up for your scheduled appointment or cancel within 24 hours of your scheduled appointment, YOU WILL BE CHARGED A $ NO- SHOW FEE. You will need to report to the sleep lab at 8:30PM unless told otherwise. WHERE: Humble Dreams Sleep Center 8901 FM 1960 Bypass Rd. Ste. 306 Humble, TX (281) Phone Please feel free to call if you have any questions about your sleep study.
4 DIAGNOSTICS AND TREATMENT SLEEP QUESTIONNAIRE Name: 1. If this is someone other than the patient filling out this form, please indicate your relationship to the patient: _ 2. Why has your physician referred you for a sleep study? Check all that apply or describe: I snore loudly at night. My snoring disturbs my bed partner. I have been told that I quit breathing at night. I have trouble falling asleep or staying asleep at night. I am tired and sleepy during the day. Additional comments: _ 3. Have you ever had a sleep study? If so, when and where? _ 4. Are you currently on CPAP therapy? If so: What pressure are you presently using? Does the mask fit OK? Do you use it every night? Does it seem to help? 3. Age: 4. Height: 5. Weight:
5 6. Neck or collar size: 7. Marital Status: Single Married Separated Divorced 8. Have you recently gained weight? If so, how much? 9. Do you smoke? If so, how much and for how long? 10. Do you consume alcoholic beverages? If so, how much? 11. Do you consume beverages with caffeine in the afternoon or evening? If so, how much? 12. What kind of work do you do? 13. Please list all major medical problems: 14. Please list the prescription medications you take: 15. Please list the over- the- counter medications you take: 16. Are you allergic to any drugs? If yes, please list:
6 17. Do you suffer from frequent nasal congestion? 18. Have you had nasal or sinus surgery? If yes, please describe: YOUR SLEEP PATTERNS: 1. What time do you usually go to bed? Weekdays: Weekends: 2. What time do you usually wake up? Weekdays: Weekends: 3. Do you do shift work? If so, describe your sleep schedule: 4. Do you take naps during the day? If yes, when, how many, and for how long? 5. Are the daytime naps refreshing? 6. Do you take any medicines to help you fall asleep? If so, please list How many times per week? 7. Do you consume alcohol within a few hours of bedtime? If so, how much? How many times per week? 8. Do you have trouble falling asleep at night? If so, why? 9. Do you worry that you may not be able to sleep? 10. Do you feel that you have to try hard to fall asleep? 11. Do you wake up at night?
7 If so, how often and why? 12. Do you have trouble falling back asleep once awake? 13. Do you experience crawling and aching feelings in your legs which makes you want to move them or walk? 14. Do you suffer from pain that interferes with your sleep? If so, please explain: 15. Do your legs jerk before or during sleep? 16. Do you wake up with dry mouth? 17. Do you feel refreshed when you wake up in the morning? 18. Do you have a headache when you wake up in the morning? 19. Do you grind your teeth together while sleeping? 20. Do you sleepwalk? 21. Have you ever walked in your sleep? If so, at what age: 26. Do you have frequent nightmares? 27. Have you injured yourself or a bed partner acting out dreams? If so, please explain: 28. Do you experience vivid dreams upon falling asleep or waking up? 29. Have you had spells where you feel that you are unable to speak or move when you are about to fall asleep or when you are awakening? DURING THE DAY: 1. Have you experienced sudden muscle weakness (that makes you fall or causes your knees to buckle)? When laughing? When angry? Other: 2. Do you feel tired during the day?
8 3. Are you sleepy or groggy during the day? 4. Does sleepiness interfere with your work? 5. Have you experienced sudden or uncontrollable sleep attacks? 6. Do you get sleepy while driving? Additional Comments: (Comments from your bed partner would be very useful) Epworth Sleepiness Scale Instructions: Please give the answer that most accurately describes the chances of you dozing off or falling asleep in the following situations. This refers to your usual way of life in recent times. 0 - Never; 1 - Slight; 2 - Moderate; 3 - High Sitting and Reading Watching Television Sitting Inactive in a Seminar, Theater, or Meeting As a Passenger in a Car for One Hour Lying Down to Rest in the Afternoon
9 While Having a Relaxed Conversation Sitting Quietly After Lunch In a Car While Stopping at a Traffic Signal Total Points (Max/24) Please note unless your referring physician has requested otherwise, you will be contacted by our office for an appointment to follow up with the sleep disorder specialist approximately 6 weeks after your CPAP has been delivered. This appointment ensures that your machine is working properly and that you are getting the appropriate treatment for your sleep disorder. Also, if you would like to discuss your sleep study results with the sleep specialist before receiving your CPAP, please feel free to contact our office at (281) X Signature Date
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Sleep Disorders Center of Santa Maria
SLEEP QUESTIONNAIRE Patient Name: Sex: Date of Birth: Occupation: Usual Work Hours/Days: Referring Physician: Family Physician: Marital status: Single Married Divorced Widowed Please complete the following
Sleep Medicine Questionnaire
Please bring this completed questionnaire with you to your sleep medicine appointment. Our sleep medicine staff strives to understand your sleep symptoms, which may be complex in nature. Thank you for
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
EPWORTH SLEEPINESS SCALE
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
Adult Sleep Questionnaire. Name: (First) (middle) (Last) Address: (Street) (City) (State) (Zip) Marital Status: Spouse s Name:
Adult Sleep Questionnaire Date: / / Name: (First) (middle) (Last) Address: _ (Street) (City) (State) (Zip) Date of birth: / / Age: Home Phone: ( ) - Work Phone: ( ) - Height: Weight: Neck Size: Marital
Original Sleep Hygiene Rules*
Original Sleep Hygiene Rules* 1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing time in bed a bit seems to solidify sleep; excessively long times
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
VERY IMPORTANT INFORMATION
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
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
DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following
DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting
General Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
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
Insurance information
Pediatric Sleep Intake Paperwork Today s date: Completed intake paperwork helps our providers get to know patients and their medical history. We rely on its accuracy and completeness to provide the best
MEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
PEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
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