PATIENT INFO SLEEP VISIT
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- Brandon Ward
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1 Pulmonary Associates of LVPG A practice of Lehigh Valley Physician Group 1250 S. Cedar Crest Blvd., Suite 205, Allentown, PA Bathgate Drive, Suite 403, Bethlehem, PA (phone) (fax) PATIENT INFO SLEEP VISIT Today s Date Name: Address: Date of Birth Phone Race: Black/African American American Indian/Alaskan Native/Eskimo Multi-Racial Pacific Islander Asian White Unavailable Refused Unknown: patient unsure of race Ethnicity: Hispanic/Latino Not Hispanic/Latino Unavailable Refused Place of Employment: Occupation:_ Phone Marital Status: S M W D Sep Sex: M F SS# _ Spouse Name: DOB SS# Referring Physician Name: _ Address: Phone Pharmacy Name: Address: Phone Do you have an Advance Directive (Living Will or Durable Power of Attorney)? If no, would you like information about Advance Directives? A. Describe your sleep/wake complaint: (What actually brings you here?) 1. Do you have trouble falling asleep? 2. Do you have trouble staying asleep? 3. Do you have abnormal movements/behaviors during sleep? B. The following questions are about your typical schedule: 1. What time do you usually go to bed? AM PM 2. What time do you usually get out of bed? AM PM 3. How long does it take you to fall asleep? 4. How many times are you awakened from sleep each night? 5. Once awake, how long does it take you to go back to sleep? 6. How many hours of sleep do you estimate you get per night? 7. Are you a shift worker? 8. What shift do you or did you work? PALVPG 05 Rev 01/13
2 C. The following are questions about how sleepy you feel during your awake time. How likely are you to doze off or fall asleep in the following situations? This refers to your usual way of life in recent times. Please 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 SITUATION Sitting and reading Watching TV Sitting, inactive in a public place (e.g., movie, meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopped for a few minutes in traffic CHANCE OF DOZING 1. Do you feel refreshed upon awakening? 2. How long have you been sleepy? 3. Is your daytime sleepiness mild moderate severe 4. Are you sleepy at work? 5. Do you fall asleep at work? 6. Do you fall asleep when driving your car? 7. How many times have you fallen asleep while driving? 8. After how many minutes of driving do you become sleepy? 9. Have you had any car accidents due to sleepiness? 10. Do you take naps during the day? 11. Do you feel refreshed after a nap? 12. Is your daytime performance in work or recreation less efficient than you would like it to be? 13. Are you having problems with your memory? 14. Do you have trouble concentrating during the day? 15. Do you have uncontrollable urges to fall asleep during the day? 16. Do you have hallucinations or dream-like mental images when you are falling asleep? 17. Do you feel paralyzed when falling asleep? 18. Do you have attacks of sudden physical weakness or paralysis during the day, when laughing, angry or in other emotional situations? D. The following questions concern symptoms and behaviors related to sleep: 1. Have you ever been told that you snore loudly? 2. Does your bed partner say that you stop breathing when you are sleeping? 3. Do you sometimes wake you feeling like you are choking or gasping for breath? 4. How many mornings per week do you awaken with a headache? 5. Is your mouth dry upon awakening in the morning? 6. Do you have restless legs when you lie down in bed before you fall asleep? 7. Have you ever been told your legs twitch during the night? 8. Do you walk in your sleep? 9. Do you talk in your sleep? 10. Do you grind your teeth during sleep? 11. Do you wet the bed during sleep? 12. Do you have frightening dreams or nightmares?
3 E. The following questions deal with medical problems that can affect sleep: 1. Do you have arthritis, joint pain or back pain? 2. Have you ever had a convulsion (e.g. fit, epilepsy, seizure)? 3. How much weight have you gained in the past year? 4. What is your neck size? 5. Do you have nasal stuffiness? 6. Have you ever suffered from a head injury? 7. Do you feel depressed, sad or blue during the day? 8. Would you classify your depression as: mild moderate severe 9. Do you frequently feel anxious or worried during the day? 10. If you are a woman, are you pregnant? 11. If you are a woman, are you past menopause (change of life) or are you having menopausal symptoms now? 12. Are your sleep complaints cyclical (occurring only in the evening, every 10 days, when you sleep away from home, etc)? 13. Do you have palpitations during the night? 14. How many times per week do you wake up from sleep and eat something other than water before going back to sleep? 15. Are you awake at night because of nausea/vomiting? 16. Have you ever been told that you have Fibromyalgia? F. Medication/Drug History: Please list your current prescription medications (use a separate sheet if more space is needed) Name of Medication Dosage Times per day Reason Length used Prescribing Physician 1. Which non-prescription drugs do you use?
4 G. Alcohol, Tobacco and Caffeine History: 1. How much alcohol (beer, wine, liquor) do you drink each week? ounces drinks 2. How much tobacco do you smoke per day? packs cigars pipes 3. How many of the following beverages do you consume? # Per day # After 6:00 pm Caffeinated Beverages Coffee, regular/decaf Tea, regular/decaf Soft drinks (Pepsi, Coke, etc.) H. Allergies Drugs (ex. Penicillin, aspirin, sulfa, etc): Please list drugs and reaction. I. Medical History: What medical conditions are you presently being treated for? J. Family History: (Please check the appropriate box) Father Mother Son/Daughter Sibling Sibling Living Deceased Age Snoring Sleep Apnea High Blood Pressure Heart Attack Angina Stroke Diabetes Narcolepsy
5 K. ROS (Review of systems): Do you have any of the following? (Check all that apply) General Fever Sweats Loss of appetite Chills Night sweats Weight gain Weight loss Eyes Cataracts Dry eyes Glaucoma Blindness Double vision Ear, Nose and Throat Nose bleeds Earaches Snoring Sinus condition Mouth sores Nasal polyps Change in voice Heart Disease Angina Chest pain Pain in the leg walking Bad veins in your legs Palpitations Phlebitis Swelling of ankles Gastrointestinal Trouble swallowing Nausea or vomiting Heartburn Pain in abdomen Constipation Diarrhea Ulcer Black bowel movement Blood in bowel movement Food sticks in throat with swallowing Genitourinary Kidney stones Burning on urination Blood in urine Trouble starting stream Frequent urination Musculoskeletal Arthritis (joint pain) Collapsed vertebra Swelling in joint Curvature of the spine Chronic back pain Skin Rashes: describe Neurological Seizures Fainting Migraines Weakness/Numbness Dizziness Psychiatric Depression Anxiety Endocrine Low blood sugar High blood sugar Thyroid condition Hematologic/ Lymphatic Anemia Use aspirin often Bleeding tendency Swollen glands Hemophilia Blood clots Allergic/ Immunologic Hay fever Allergy injections If you have any other conditions/symptoms, please list:
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SLEEP QUESTIONNAIRE Patient Name: Sex: Age: Date: Occupation: Usual Work Hours/Days: Family Physician (PCP): Ht Wt Neck Size: What was your weight one year ago? Five years ago? Marital status: (circle
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
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 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
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
Home Sleep Testing Questionnaire
Home Sleep Testing Questionnaire Patient Name: DOB: / / Gender: Male Female Study Date: / / Marital Status: Married Cohabitate Single Divorced Widow/Widower Email: Phone: Height: Weight: Neck Size: What
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
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Intake Questionnaire
Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK=
993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD
993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD Atlanta, Georgia 30342 David E Westerman, MD 404-303-1700/ Fax: 404-252-9527 Alex Hebert, NP-C To our New Sleep Patient: On behalf of North Atlanta
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like t like
Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305
Patient Information Arizona Grand Medical Center 3777 Crossings Drive Prescott, AZ 86305 Home Phone: Cell Phone: Last Name: First Name: MI Mailing Address: APT City/State/Zip Sex: Male Female Birthdate:
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.
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
Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services.
Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services. Pa ent Iden fica on: Pa ent name: Date: Age: Date of birth: Who is filling out this ques onnaire? Please