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3700 WASHINGTON AVENUE EVANSVILLE, IN 47750 (812) 485-7680 NEW PATIENT QUESTIONNAIRE-ADULT PART 1. PATIENT INFORMATION Name Hme Phne Date f Birth Scial Security Number Wrk Phne Tday s Date Physicians Caring Fr Yu (family dctr, medical specialists, and psychlgists, and if lcated utside Evansville, please list the twn als.) Please list bth the first and last name. Did yu have help filling ut this questinnaire? If s, wh helped? PART 2. MAIN COMPLAINT What is yur main sleep r alertness cmplaint? Hw lng has it ccurred? If yu have ever had a sleep study, please indicate when and where. PART 3. DAYTIME SLEEPINESS Hw wuld yu rate yur usual daily sleepiness? Nne Mild Mderate Severe What is the sleepiest time f the day? If yu are excessively sleepy r fatigued, hw lng has this been ging n? D yu have any idea as t why this is happening? D yu fall asleep r becme sleepy when: Never Smetimes Often Always Driving? 1 2 3 4 At wrk? 1 2 3 4 Watching TV/reading? 1 2 3 4 Sprts/church/scial activities/schl? 1 2 3 4 D yu take intentinal naps? 1 2 3 4 7135-11 Page 1 f 6 Rev. 4/17

PART 4. SLEEP ROUTINE When d yu g t bed n weekdays? Weekends? Hw lng des it take t fall asleep? D yu have truble falling asleep? Hw ften d yu awaken at night? What causes it? Hw lng are yu awake? Hw ften d yu urinate at night? What time d yu get up n weekdays? Weekends? Hw many hurs f sleep d yu get in a typical night? D yu sleep alne usually? Hw d yu feel when yu get up? When yu try t relax in the evening r sleep at night, d yu ever have unpleasant, restless feelings in yur legs that can be relieved by walking r mvement?! Yes! N PART 5. SLEEP EVENTS While asleep d yu: Never Smetimes Often Always Ask yur bedpartner r smene wh has bserved yu sleeping abut these 6 items: Snre? 1 2 3 4 Stp breathing? 1 2 3 4 Gasp r chke? 1 2 3 4 Grind yur teeth? 1 2 3 4 Have jerks r twitches? 1 2 3 4 Mve yur arms r legs? 1 2 3 4 Have heartburn r chest pain? 1 2 3 4 Have nightmares? 1 2 3 4 Sleep in an unusual psitin? 1 2 3 4 Wake up with a sre thrat? 1 2 3 4 Wake up with a dry muth? 1 2 3 4 7135-11 Page 2 f 6 Rev. 4/17

PART 6. PARASOMNIAS D yu smetimes awaken with a feeling yu are cmpletely paralyzed briefly? D yu ever hallucinate sights r sunds while falling asleep as if yur dreams are beginning befre yu re fully asleep? D yu sleepwalk, talk, r man? D yu perfrm unusual behavirs during sleep? D yu have brief attacks f muscle weakness? PART 7. SLEEP HYGIENE D yu drink beverages with caffeine (cffee, tea, cla, Muntain Dew, etc.) r take caffeine pills? If s, hw much and what time f day? Hw much chclate d yu eat r drink n an average day? D yu exercise rutinely? If s, what time f day? D yu d anything stressful r anxiety prvking befre ging t bed? Is there anything in yur bedrm that culd be disturbing yur sleep? Examples are rm temperature, nise, lights. D yu nap mre than nce a week? If s, please describe. D yu smke r therwise use tbacc? If s, hw much each day? If yu quit, when was it? Hw much alchl d yu drink per day r per week? If yu quit, when was it? D yu use marijuana, ccaine, hallucingens (LSD, mescaline, angel dust), stimulants (meth, uppers), depressants (dwners), narctics (herin, mrphine, OxyCntin), r illicit drugs. If s, hw ften? 7135-11 Page 3 f 6 Rev. 4/17

PART 8. MEDICATIONS Please list all the current medicatins, vitamins, herbal supplements, and xygen yu currently take and the dses, r else attach a list. PART 9. ALLERGIES: If nne, please state s, therwise list them. PART 10. OPERATIONS: 7135-11 Page 4 f 6 Rev. 4/17

PART 11. ILLNESSESS AND INJURIES: Please list all medical cnditins and serius injuries. Hypertensin Athersclertic heart disease r heart attack Strke Epilepsy r Seizures Restless legs syndrme Diabetes High Chlesterl Chrnic sinus prblems COPD, emphysema, r asthma Thyrid disease Fibrmyalgia Lw back pain Arthritis Other Depressin PART 12. FAMILY HISTORY Please list medical cnditins in bld relatives (parents, siblings, children) and wh the relative is. Examples include high bld pressure, strke, heart attack, and diabetes. Any sleep-related disrders in the family? 7135-11 Page 5 f 6 Rev. 4/17

PART 13. REIVEW OF SYSTEMS: D yu have prblems related t: (Please elabrate if pssible.) Breathing while awake Frequent headaches Heartburn Anxiety Depressin Seizures Lng term pain cnditin Lss f sex drive r perfrmance Difficulty with cncentratin r memry Irritability r md swings Weight gain r lss ver the last few years D yu have dreams? PART 14. SOCIAL HISTORY Occupatin Marital Status Number f Children Wh lives at hme? PART 15. ADDITIONAL INFORMATION Over the past tw weeks, have yu felt dwn, depressed, r hpeless? Over the last tw weeks, have yu felt little interest r pleasure in ding things? Is there anything else yu feel may be imprtant fr the physician t knw abut yur sleep and alertness prblems r yur health? 7135-11 Page 6 f 6 Rev. 4/17

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