SLEEP QUESTIONNAIRE. BMI: (Risk if >30) Neck Circ: (Risk if: Male >16.5, Women >15)
|
|
|
- Chloe Heath
- 5 years ago
- Views:
Transcription
1 SLEEP QUESTIONNAIRE Name: Date: Please place a check mark next to any of the following symptoms you are experiencing: Difficulty falling asleep and/or insomnia Excessive daytime sleepiness and/or fatigue Snoring Has any bed partner noticed you not breathing while asleep, waking up gasping or choking? Interrupted sleep patterns Sleepiness while driving Frequent morning headaches Migraines Hypertension Diabetes High cholesterol Obesity Ear pain Neck pain Depression and/or anxiety Teeth grinding and/or clenching Leg movements/restless legs Questions: Have you already been previously diagnosed with sleep apnea or another sleep related disorder? If so, how was your condition diagnosed and what treatment did you receive? If you are using a CPAP device, how often do you use it? Circle one: every night / almost every night / sometimes / infrequently / never EPWORTH SLEEP QUESTIONNAIRE How likely are you to doze off or fall asleep in the following situations? BMI: (Risk if >30) Neck Circ: (Risk if: Male >16.5, Women >15) Never = 0 Slight = 1 Moderate = 2 High = 3 Sitting and reading NEVER SLIGHT MODERATE HIGH Watching TV Sitting inactive in a public place (e.g. a theater or a 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 a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score:
2 Oregon Medical Weight Loss Patient Intake Information Best # to reach you May we leave a message here, for you? (Y/N) Alternate Phone: May we leave a message here, for you? (Y/N) Address: address City State Zip May we send you information about weight loss? (Y / N) Age D.O.B. Primary Care Provider Occupation What is your Preliminary Goal Weight? How did you hear about us? I m a current patient A friend Referred by On line via: Oregon Medical Weight Loss SW Family Physicians Other This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form in its entirety. Current Marital Status (circle one): Single Engaged Married Separated Divorced Widowed Domestic Partner Are you content with your current status? (Y/N) If no, please explain: What is your main reason for deciding to lose weight now? List activities you are not doing now, but would like to do in the future: When did you begin gaining excess weight? (Give reasons if known): What has been your maximum lifetime weight (non-pregnant) and when? Has your weight changed in the last 2-3 months? Any history of eating disorders, now or in the past? Please explain What are your expectations of us (your medical team)? Be specific: Previous diets you have followed: Dates _ Results of your weight loss: Any weight regained?: Which was you best diet success and why did it work well for you. How often do you eat out? How often do you eat fast foods? In your household, who plans meals? Cooks? Shops? Is your spouse or partner overweight? NO YES If so, approximately how much? Foods you crave? What are your worst food habits? Please describe your snack habits: Do you awaken hungry or eat during the night? YES NO Do you feel you are an emotional eater? YES NO Please list circumstances that trigger this emotional eating behavior. Have you used appetite suppressants in the past? YES NO If so, which ones? What were the results? If your favorite food is in the refrigerator, do you find it hard to sleep well? YES NO 1
3 Typical Breakfast Typical Lunch Typical Dinner Please list any conditions, illnesses, or treatments that might be relevant to your visit today: Do you feel you are you in good health at the present time? YES NO If not, why? Are you under any other doctor s care at the present time? If yes, Who? (and for what) Do you drink sodas? YES NO How much daily? Do you use a sugar substitute? YES NO Do you drink alcohol? YES NO How much daily/weekly? Do you drink coffee or tea? YES NO How much daily? Smoking Habits: I have never smoked cigarettes, cigars, or a pipe. I quit smoking years ago and have not smoked since. I quit smoking at least one year ago and now smoke cigars or a pipe w/out inhaling smoke. I smoke approx cigarettes per day ( pack/s) Any Medication Allergies? Food Allergies? Please list all prescription medications you are taking at the present time: Drug: Dosage: Taken for what reason? Any over-the-counter medications, vitamins, herbs, supplements or natural remedies? Serious Injuries/ Surgeries (please list all) Date Behavioral Health When you are in a stressful situation that is work or family related, do you tend to eat more? Explain Are you currently undergoing any stress or emotional upset? Explain: Are you currently experiencing any suicidal thoughts? Have you seen a mental health provider for services? Please explain: Have you ever been hospitalized for psychiatric, drug, or alcohol addiction? Date: Hospital: Diagnosis: 2
4 OB/Gynecologic History: (Women only) Number of Pregnancies: Vaginal Delivery or C-Section: Babies over 9 lbs? YES/NO If yes what were their weights? Menstrual Onset: yrs old Duration: days Last menstrual period: Do you have pain associated with menstrual cycle? YES/NO Are menses heavy? Are you on Birth Control? YES/NO If yes, please list: On Hormone Replacement Therapy? YES/NO If yes, please list: When was your last Physical/ PAP? Check ALL the weight related Risks or Diagnoses that you may have: Abdominal Pains Abnormal EKG Abnormal Weight Gain Anemia Anorexia Nervosa (now or in the past) Anxiety Arthritis Asthma Breast Cancer Binge Eating patterns/disorder Bulimia/Purging (exercise, laxatives, vomiting, diuretics) Constipation Cushing s Syndrome Decreased Libido Depression/dysthymia Diarrhea Diabetes Dizziness Eating in the middle of the night Elevated Liver Enzymes Fatigue Fibromyalgia Frequent Headaches GERD Heartburn Gestational Diabetes Glaucoma Gout Hip Pain High Blood Pressure Pre-Hypertension High Cholesterol Triglycerides Insomnia Irritable Bowel Knee Pain Low Back Pain Low Blood Sugars Low Testosterone Menopause Migraines Muscle Spasm Nausea Vomiting Osteoporosis Panic Attacks Painful, heavy, or irregular menses Plantar Fasciitis Polycystic Ovarian Syndrome Pre-diabetes Psoriasis Sleep Apnea Snoring Swelling feet or ankles Thyroid Disorder Ulcer Urinary Stress Incontinence Family History: AGE HEALTH DISEASE CAUSE OF DEATH OVERWEIGHT? Father: Mother: _ Brothers: Sisters: _ Has any blood relative had any of the following: Glaucoma: YES NO Who: Asthma: YES NO Who: Epilepsy: YES NO Who: High Blood Pressure: YES NO Who: Kidney Disease: YES NO Who: Diabetes: YES NO Who: 3
5 Psychiatric Disorder: YES NO Who: Heart Attack: YES NO Who: Heart Disease: YES NO Who: Stroke: YES NO Who: Overweight/Obesity YES NO Who: Activity Level (answer only one): Inactive/ Sedentary- includes only the light physical activity associated with typical day-to-day life Moderate Activity- includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour (in addition to the light physical activity associated with typical day-to-day life) Active- includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, (in addition to the light physical activity associated with typical day-to-day life) Please check all that apply to you currently Stress Unhappiness Inferiority feelings Fears Depression Anger Racing thoughts Friends Impulsive behavior Ambition Finances Panic Apathy Hopelessness Alcohol use Temper Physical abuse Problems concentrating Loss of control Sexual problems Death Pregnancy Making decisions Parenting Unwanted thoughts Abortion Shyness Communication Sexual abuse Bad dreams Marriage Trauma/disaster Trouble with job Children Nervousness Emotional abuse Anxiety Guilt Grief Loneliness Memory loss Compulsivity Legal matters Please indicate your level of motivation to lose weight on the scale below: Unmotivated Neutral/Unsure Very Motivated Do you have any interest in getting more information about how the other specialties in our clinic may enhance or assist you in your weight loss? (Please circle all that apply): Nutritional Counseling - Acupuncture - Medi-Spa - Physical Therapy - Massage Therapy - Mental Health/ Counseling - Personal Training Signature: 4
6
INTAKE FORM at Oregon Medical Weight Loss & Wellness
Name: Date: Best # to reach you May we leave a message here, for you? (Y/N) Social Security Number Address: Email address City State Zip May we send you email information about weight loss? (Y/N) Age D.O.B.
Patient Medical History Form
Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
Weight Loss- Medical History Form
Weight Loss- Medical History Form Name: Age: Sex: M F Family Physician: Phone: May we contact this practitioner? Yes No Present Status: 1. Are you in good health at the present time to the best of your
Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No
Medical History Form Name: Age: Sex: M F Family Physician: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor s care at
Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor:
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
SLEEP DISORDERS CENTER QUESTIONNAIRE
Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY
Nebraska Bariatric Medicine 8207 rthwoods Dr., Suite 101 Lincoln, NE 68505 MEDICAL HISTORY Name Today s Date The following page allows you to complete what we call a weight timeline. This is a very valuable
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
Bariatric Surgery Patient History Questionnaire
Bariatric Surgery Patient History Questionnaire Your appointment will be delayed if this form is incomplete please print legibly Personal Information Name Date SSN# (for insurance purposes) - - Date of
EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:
EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?
PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
Date of Birth: City: State: Zip: Home phone: Who is your primary care physician?
PERSONAL INFORMATION Name: Address: Date of Birth: Mobile phone: City: State: Zip: Home phone: Email: Who is your primary care physician? Phone: How did you hear about The Nebraska Medical Center Bariatrics
Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715
Patient Packet Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Welcome Thank you for your interest in SSM Health Weight Management Services. Please complete the enclosed questionnaire
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
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
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
Associated Neurological Specialties and Sleep Disorder Center
Sleep Center Questionnaire Name: Sex: Age: Date: Date of Birth: Height: Weight: Neck Size: Primary Care Physician: Referring Physician: Main Sleep Issues/Complaints Trouble falling asleep Trouble staying
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE. Name: Date of Birth: / / Age: Sex: Address: City: Zip:
MICHIGAN INSTITUTE FOR SLEEP MEDICINE NEW PATIENT SLEEP QUESTIONNAIRE *Please bring copies of any recent Blood Work and Physician Sleep Referral Order* Please answer every question to the best of your
Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ
Background Information Andrea Berez, MS, RDN Registered Dietitian Nutritionist 6 Auer Court, Suite D, East Brunswick NJ 08816. aberezrd@njpedsrd.com Adult Patient Nutrition Assessment/Diet History Form
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
1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
Telephone: Fax:
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
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:
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
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:
Sleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:
Lyris Bacchus Steuber, MS, LMFT MT 2075 515 Harley Lester Lane Apopka, FL 32703 Ph: 407 417 7770, Fax: 407 862 4820 Please complete the following so I can have a better understanding of how I can help
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
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
Sleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
Bariatric Surgery. Website: http//baybariatricsurgery.com
Bay Bariatric Surgery Kevin L. Huguet, M.D. General Surgery Laparoscopic Surgery Bariatric Surgery George Rossidis, M.D. General Surgery Minimally Invasive Surgery Bariatric Surgery Website: http//baybariatricsurgery.com
PATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
Patient Information Form
Patient Information Form Patient Name: (Last) (First) (MI) Name you prefer to be called: Patient Address: City: State: Zip: Home Phone: Cellular: Birthdate: Age: Sex: M F Email: Employment Information:
12 Reasons. Why I Want to Reach My Goal Weight
WeightLossNYC, page 1 12 Reasons Why I Want to Reach My Goal Weight Name: Date: Before writing your reasons down, give them some thought. It is important that these 12 reasons be true personal goals and
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA 70301 985-493-4759 SLEEP HISTORY QUESTIONNAIRE DATE: / / NAME: AGE (First) (Middle) (Last) ADDRESS: (Street) (City) (State) (Zip) PHONE: Home( ) Work:( )
Sleep Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
PATIENT HEALTH HISTORY FORM:
PATIENT HEALTH HISTORY FORM: It is very important to know your detailed medical history information to assess your health. Obesity and its associated diseases and risk factors increase mortality and surgical
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
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
Welcome to the Koala Center for Sleep Disorders
Welcome to the Koala Center for Sleep Disorders Your health is very important. We are honored to have the opportunity to join you on your wellness journey. In order to provide you with the comprehensive
Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. For how many months/years?
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
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:
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
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
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
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
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:
FHN Medical Weight Management Program
Date: Medical History Form Name: Date of Birth: Sex: M F Primary Healthcare Provider: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you
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
Journey to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
Mercy Metabolic and Bariatric Surgery Program Questionnaire
Mercy Metabolic and Bariatric Surgery Program Questionnaire Interested in bariatric surgery? Complete this form and return to us to be considered for evaluation: Sara Maduka, Mercy Metabolic and Bariatric
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
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,
Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:
PATIENT INFORMATION (Please Print) Today s Date : Patient s last name: First: Middle: M Jr. Sr. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your
Sleep Patient Registration
Sleep Patient Registration Name: Birthdate: Age: City, State, Zip: If patient is a minor, parent or guardian name: Home Ph: Work Phone: Cell: Social Security#: E- Mail: Gender: Female Male Married Single
SLEEP & MEDICAL HISTORY QUESTIONNAIRE
SLEEP & MEDICAL HISTORY QUESTIONNAIRE Patient Name Sex Age Date Please complete the following questionnaire by placing a check in the appropriate areas and filling in the blanks. My Main Sleep Complaint(s)
Littleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
Littleton, CO Welcome Packet For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 8151 Southpark Lane, Suite 200, Littleton,
First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age
Date Time Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight loss plan. A
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-9 months?
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy or Danville Are you a Christie registered patient? Yes No Have you had labs (lipid
Sleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?
Onslow Medical Specialties Clinic Lung Diseases & Sleep Disorders Clinic Pulmonary Function Test/ CardioPulmonary Exercise Test/ Thoracic Ultrasound Methacholine Challenge Test/ Video-Flexible Laryngoscopy/
Now is the time for a trimmer, healthier you.
Weight No More! Now is the time for a trimmer, healthier you. Medical Director: Peter Ruggiero, M.D Bariatric Physical Exam Name: Age: Date: Vital Signs: BP (sitting) Pulse Height (w/o shoes) inches Weight
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
WellSpan Medical Weight Management 2339 South George Street York, PA (717)
1 WellSpan Medical Weight Management 2339 South George Street York, PA 17403 (717) 851-6207 We appreciate the time you have taken to complete this form and the food log, since they will provide helpful
Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
Health Profile ALTH PROFILE Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss
Rex Surgical Specialist (Bariatric Office)
Rex Surgical Specialist (Bariatric Office) Medical History Information Today s Date Name DOB Referring Physician phone_ Primary Care Physician phone_ Office Office Medical History (Please Mark all that
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
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
Kelowna Sleep Clinic Dr. Ronald Cridland Inc Sleep Questionnaire
Dr. Ronald Cridland Inc Sleep Questionnaire Name: Date: d/m/yr Date of Birth: d/m/yr Age: Marital Status: Sex: M F Address: City: Province: Postal Code: Health Care #: Home Phone #: Work Phone #: _ Cell
BARIATRIC PROGRAM PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY)
BARIATRIC PROGRAM PERSONAL INFORMATION PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY) Name: Date: Sponsor s SSN# - - Date of Birth: Age: Mailing Address: City: State: Zip: Mobile Phone: Home
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Sleep Center New Patient Questionnaire
For office use only Appt date: Sleep Center Clinician: Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 #1 respiratory hospital
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
SLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
Sleep Disorders Questionnaire
Sleep Disorders Questionnaire NAME: DATE: ADDRESS: DATE OF BIRTH: AGE: SEX: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: SINGLE: MARRIED: WIDOW(ER): DIVORCED: SEPARATED: REFERRING PHYSICIAN: ADDRESS:
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
SLEEP HISTORY QUESTIONNAIRE
Date of birth: Today s date: Dear Patient: SLEEP HISTORY QUESTIONNAIRE Thank you for taking the time to fill out a sleep history questionnaire. This will help our healthcare team to provide the best possible
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
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
Patient Medical History Form
Patient Medical History Form Name: Age: Sex: M F Medications currently taking: (Prescription, over-the-counter, vitamins, supplements) DRUG ALLERGIES Past Medical History or Chronic Current Medical Conditions:
Physician Assisted Weight Loss Program. Patient Name: Date: Patient Address: City: State: Zip:
Physician Assisted Weight Loss Program Patient Name: Date: Patient Address: City: State: Zip: DL / ID #: Phone Number: Birthdate: Age: E-mail: Employment Information: Patient Employer: Occupation: City:
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
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
Patient History & Sleep Questionnaire
Patient History & Sleep Questionnaire Patient Full Name: Nick Name: Birth date: Age: Sex: Height: Current Weight: Weight Five Years Ago: Peak Lifetime Weight: Marital Status: Single Married Divorced Widowed
Adult Health History Form Preferred Name: 1
Adult Health History Form Preferred Name: 1 Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions. If you are uncomfortable with
What is the chief complaint for which you are seeking treatment in our practice?
Call 1300 7SNORE www.puresleepservices.com.au New Patient Form Please take your time to answer these questions as completely as possible. It will assist us greatly in our effort to provide the best treatment
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
Single Married Divorced Widowed Male Female
Annual Physical Form General Information Name Birth Date Phone Email Address Street Address City State Zip Marital Status Gender Single Married Divorced Widowed Male Female Employment Information Position
Dr. Edmund P. Chute, MD
Date attended class: Dr. Edmund P. Chute, MD Procedure of choice: Laparoscopic Roux-en-Y gastric bypass Sleeve Gastrectomy Unsure Personal Information: First Name: Middle Initial Last Name Social Security: