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 legal name? (Former name): Birth date: Age: Sex: Yes No M F Street address: Social Security no.: Home phone no.: P.O. box: City: State:Fl ZIP Code: Occupation: Employer: Employer phone no.: ( ) Chose clinic because/referred to clinic by (please check one box): Dr. Insurance Plan Hospital Family Friend Close to home/work Yellow Pages Other family members seen here: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: Patient / / Same as above ( ) Is this person a patient here? Yes No Occupation: Employer: Employer address: Employer phone no.: Is this patient covered by insurance? Yes No ( ) Please indicate primary insurance Aetna Avmed Blue Cross Cigna Medicare Medicaid First Health United Healthcare Tricare Prime Standard Other Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: Patient s relationship to subscriber: Self Spouse Child Other / / $ Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Patient s relationship to subscriber: Self Spouse Child Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( )
Date: check ( ) here if you provided your own list of medications Medications List medications you are currently taking Name of Medication Dosage How many times a day? Family History- please check ( ) all that apply regarding your family s health Please check here if you were adopted or otherwise have no knowledge of your family s medical problems Yourself Mother Father Sister Brother Aunt Uncle Sleep apnea Narcolepsy Diabetes Mellitus type II Hypertension (high blood pressure) Arthtritis Gout Restless Legs Allergic rhinitis (hay fever) Asthma Heart disease Migraine Headaches High Cholesterol Cancer Kidney Disease Liver Disease Stroke Tuberculosis Other:
Review of Symptoms Check ( ) conditions you currently have Allergies to medications: NONE Muscul-skel Pain in: Arms Legs Back Neck Feet Hands Knees Elbows Social History Check ( ) all that apply CV Palpitations Chest pain Swelling of the feet GI Nausea Vomiting Vomiting blood Rectal bleeding Diarrhea Constipation Stomach pain Eyes Blurred vision Pain Itching Skin Bruise easily Rash Change in moles Hives Non-healing sore GU Blood in urine Painful urination Painful intercourse Discharge from penis or vagina Resp Short of breath Cough Cough up blood Exposed to asbestos Neuro Headache Dizziness Numbing Tingling Psych Moody Nervousness Forgetfulness Hallucinations Depressed ENT Sinus problems Snoring Hearing loss Bleeding gums CAFFEINE: How much caffeine do you consume on a daily basis? caffeinated beverage ( cola, Mountain Dew etc.) How many cans per day? Tea Coffee How many cups per day? TOBACCO: never quit currently smoke currently chew How many packs per day? How many years? ALCOHOL: never quit occasional daily beer liquor cocktails ILLICIT DRUGS: never quit occasional daily What are you using? WORK: retired disabled student currently employed work days work nights shift work What is (or was) your occupation? HOME: married divorced widowed single children How many children?
Yes No Have you had problems with worsening daytime sleepiness? Yes No Do you feel distracted and unable to concentrate during the day? Yes No Have you had any accidents at work or while driving due to sleepiness? Yes No Have you had an auto accident in the last 5 years? Yes No Has anyone told you that you snore loudly? Yes No Have you ever awakened gasping for breath, coughing or choking? Yes No Has your family told you that you quit breathing at night? Yes No Do you awaken with a sore throat or sour taste in your mouth? Yes No Do you have morning headaches? Yes No Has your weight changed in the last 5 years? Gained / Lost lbs Yes No Have you ever awakened at night with a burning sensation in your chest? Yes No Do you have sudden episodes of sleep during the day? Yes No Have you ever experienced periods in which you feel paralyzed while going to sleep or waking up? Yes No Have you ever had visual hallucinations or dream-like mental images when falling to sleep or waking up? Yes No Did you have childhood sleep problems of any type? Yes No Were you excessively sleepy as a teenager or young adult? Yes No Do you take scheduled naps during the day? Yes No Do you sleep better away from your own bed? (vacations, visiting family) Yes No Do you kick your legs at night? Yes No Do you have tingly sensations in your legs or just have to move them? Yes No Do you have difficulty initiating sleep at night? Yes No Do you have difficulty maintaining sleep at night? Yes No Do you have frequent awakenings? Yes No Do you have frequent nightmares?
Yes No Do you ever wake up screaming at night? Yes No Do you grind your teeth in your sleep? Yes No Have you ever had a severe head trauma? Yes No Do you sleep walk? Yes No Do you wet the bed at night or get up frequently to urinate? Yes No Do you talk in your sleep? Yes No Do you usually have restless sleep? Yes No Do you ever act out your dreams? Yes No Do you have pain that bothers you at night? Yes No Are you awake at night because of your bed partner? (noise or movement) Yes No Are you awake at night because some other person needs assistance? (elderly or infant) Yes No Have you ever experienced sudden physical weakness during strong emotions? (such as your mouth dropping open or legs going weak or limp, during laughter or anger)
Date: 0- would never doze 1- slight chance of dozing 2- moderate chance of dozing 3- high chance of dozing Please rate the following using the scale above Chance of dozing Situation sitting and reading watching television sitting inactive in a public place such as a theater or a meeting as a passenger in a car or an hour without a break lying down in the afternoon when circumstances permit sitting and talking to someone sitting quietly after lunch without alcohol in a car, while stopped a few minutes in the traffic Please add the above for your final score