Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC Medical Histry Patient Name: DOB: Adult Sleep Questins Yes N Cmments 1 Have yu had sleep prblems in the past? 2 Have yu had any sleep tests befre? 3 D yu snre ludly? 4 Have yu been tld yu hld yur breath while sleeping? 5 D yu wake up with a dry thrat? 6 D yu have night sweats? 7 D yu need bathrm breaks after falling asleep? 8 D yu wake up with headaches? 9 D yu have chking spells during sleep? 10 Des sleep psitin affect yur snring? 11 Have yu gained ver 10 punds in the last year? 12 D any (r did any) f yur family members snre? 13 Are yu restless during sleep? 14 Have yu been tld yu kick r punch during sleep? 15 D yu have leg discmfrt relieved by mvement? 16 Fr wmen: Have yu had prblem pregnancies? 17 D yu grind yur teeth at night? 18 Des yur spuse/family/pets affect yur sleep? Circle ne 19 D yu wrry in bed? 20 D yu check the clck frequently in bed? 21 D yu watch TV in bed? 22 D yu play vide games r wrk n the cmputer befre bed? 23 D yu read in bed? 24 D yu get suddenly weak and extremely emtinal? 25 D yu ever feel paralyzed fr minutes n waking? 26 On falling asleep r waking, have yu ever nted hallucinatins? 27 Wuld yu describe yur sleep as refreshing? 28 D yu need a minimum amunt f sleep t feel refreshed? 29 Did yu have sleep prblems as a child? Tel (713) 464-4107 Visit ur website: myspecialist.clinic Fax (713) 465-4522
Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC Sleep times AM PM Cmments What time d yu try t g t sleep n weekdays? What time d yu wake up n weekdays? What time d yu try t g t sleep n weekends? What time d yu wake up n weekends? What time d yu take a nap, if applicable? Is the nap refreshing? Yes N Habits Yes N Amunt D yu currently smke cigarettes? D yu currently chew tbacc Have yu quit nictine prducts? If s, hw lng did yu use and when did yu quit? D yu drink alchlic beverages? If s, what time is yur last drink? D yu drink r eat caffeine/decaf prducts? If s, what time is the last prduct taken? D yu use, r have yu used mind altering drugs? Ttal years f use: Hw lng since yu quit: Tel (713) 464-4107 Visit ur website: myspecialist.clinic Fax (713) 465-4522
Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC D yu have a medical histry f: Yes N Year Diagnsed 1 High bld pressure/hypertensin 2 Diabetes 3 Heart disease r heart failure 4 Kidney disease 5 Strke 6 Obstructive lung disease r Asthma 7 Heart rhythm, prblems 8 Fr wmen: Plycystic Ovarian disease 9 Depressin 10 Anxiety 11 Chrnic pain 12 Reflux disease r night time heartburn 13 Seizures 14 Thyrid disease 15 Anemia 16 Fibrmyalgia 17 Arthritis Any ther medical cnditins that yu have been diagnsed with: Please list sleep medicatins that have failed and why: Medicatin name Why it failed Surgical Histry Surgery perfrmed Date f surgery Reasn fr surgery Tel (713) 464-4107 Visit ur website: myspecialist.clinic Fax (713) 465-4522
Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC Current Medicatins Time taken Name f medicatin Dse f medicatin AM PM Bed Other Medicatin Allergies Name f medicatin Type f reactin Father Mther Brther Sister Sn Daughter Paternal Grandfather Paternal Grandmther Maternal Grandfather Maternal Grandmther Family Medical Histry Please list any medical issues with members f yur family. Tel (713) 464-4107 Visit ur website: myspecialist.clinic Fax (713) 465-4522
Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC Review f Systems During the past few weeks, have yu had any f the fllwing symptms? Please check all that apply. Cnstitutinal Fever Fatigue Sleep: Prblems with sleeping Breathing difficulties Excessive sleepiness during the day Eyes: Dry eyes Eye pain Ears, Nse, and Nasal cngestin Muth Nasal discharge Ear discharge Bad breath Recurrent strep thrat Heart: Chest pain Shrtness f breath Lungs: Shrtness f breath at rest Shrtness f breath with exercise Unexpected weight lss r gain Night sweats Dry muth/sre thrat upn awakening Frequent awakening during the night Other sleep difficulties Watery eyes Itchy eyes Sinus pressure Nse bleeds Dry muth Pstnasal drip Sensatin f fluid r fullness in ear Palpitatins Swelling in the legs Cugh with sputum prductin Bld tinged phlegm r cughing up bld Lss f appetite N general cmplaints Snring Chking/gasping during sleep Mrning headaches Difficulty falling asleep Visin changes Facial pain Ear pain Tth pain Nasal ulcers Oral ulcers Racing heart N cmplaints Shrtness f breath with nrmal daily activities Wheezing Excessive mvements during sleep N sleeping prblems Sre thrat Enlarged tnsils N cmplaints Cugh withut sputum prductin N lung cmplaints N cmplaints Stmach and Intestines Nausea Abdminal pain Vmiting Diarrhea Cnstipatin Heartburn Cnstipatin Jaundice Abdminal fullness Genit-Urinary Painful urinatin Bld in urine Urgent r frequent N cmplaints System: urinatin Muscles and Jin pain Jint swelling Jint stiffness Jints: Muscle aches Muscle weakness N cmplaints Neurlgical Headaches Difficulty with Weakness Sensry changes System: Visin changes memry Tremrs N cmplaints Seizures Psychiatric: Depressin Anxiety Panic Attacks N cmplaints Hematlgic and Easy bruising Histry f bld clts Swllen lymph ndes N cmplaints Lymphatic System: Easy bleeding (DVT) Bld clt antibdy N swllen lymph ndes Endcrine and metablism: Heat intlerance Cld intlerance Frequent need t urinate Always thirsty Intermittent visin changes Prblems with thyrid N cmplaints Skin: Eczema (dry/itchy skin) Sun Sensitivity Psriasis Hives Rash N cmplaints Allergy and Immunlgy: Anaphylaxis Angidema Frequent infectins N cmplaints Tel (713) 464-4107 Visit ur website: myspecialist.clinic Fax (713) 465-4522
Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC Scial Histry Please tell us abut the patient s envirnment and scial situatin. Please check all that apply. Patient s living envirnment: Huse Apartment Trailer hme Central A/C Windw A/C units Dehumidifier Humidifier Changes air filters regularly Hypallergenic mattress encasement(s) Stuffed animals in the bedrm Carpet thrughut the hme Uphlstered furniture Drapes/curtains n the windws Hypallergenic pillw encasements Carpet in the bedrm Mildew/mld prblems in the hme Wd r leather furniture Blinds n the windws Des the patient drink alchl, r is there alchl cnsumptin in the patient s envirnment? Daily Less than nce a mnth Weekly Special ccasins nly Mnthly Nne Des the patient smke r is the patient expsed t smke? Less than 1 pack per day 1 pack per day Greater than 2 packs per day 1-2 packs per day Secnd hand smke expsure Snke expsure in the hme/car N smke expsure Wh lives in the hme with the patient? Bth parents Only mm Siblings Only dad Spuse Children Fster parent(s) Other What type f wrk des the patient (r patient s parents) d? Prfessinal Wrk in the hme Medical field Labratry wrk Expsure t txins and/r chemicals Has the patient traveled r lived utside the United States? Yes Hard labr Other N What is the patient s (r patient s parents) marital status? Single Married Divrced Other Is the patient expsed t pet(s) r animals? If s, hw many? Dgs (#) Cats (#) Birds (#) Cattle(#) Hrses (#) N pet/animals Des the patient attend schl? Elementary Cllege Middle Nt in schl High Schl Invlved in rganized sprts Des nt play sprts Invlved in extracurricular activities Des the patient (r patient s family) have the daycare expsure? Yes N Tel (713) 464-4107 Visit ur website: myspecialist.clinic Fax (713) 465-4522