HOME SLEEP TEST HSAT (Home Sleep Apnea Test)

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HOME SLEEP TEST HSAT (Home Sleep Apnea Test) Thank you for choosing Ridgeview for your health care needs! Our goal is to provide the best possible health care for the community we serve. This letter is to confi rm your scheduled sleep study and to explain what is involved with the procedure. Prior to your arrival, please review the following information about the Sleep Center. Fill out the forms included in this packet. REMINDERS FOR THE DAY OF YOUR APPOINTMENT: Bring your medication list and the completed health questionnaires. Arrive at the time you were scheduled for. If you cannot keep this time, please contact the sleep center prior to your appointment. The Ridgeview Medical Place building is locked at night, park on the front (north side) of the building and ring the buzzer to the left of the door under the larger canopy. (Refer to map in packet.) If you have any questions or concerns or need additional information, you can contact the sleep center directly at 952-442-8080. Please leave a message if nobody is available to take your call, and someone will call you back when available. If you should need to cancel or reschedule your sleep study, please contact our scheduling office as soon as possible at 952-442-8012 from 8am-4:30pm so we can fill that opening with another patient. 15101 2/18

Home Sleep Test Information Your sleep test is scheduled for at. The follow up appointment to go over test results is scheduled for or, if left blank, your appointment will be made the night of your sleep study. **PLEASE NOTE: YOUR FOLLOW UP APPOINTMENT IS LOCATED IN THE RIDGEVIEW PROFESSIONAL BUILDING (on the south side of the hospital) AT 560 S. MAPLE STREET, SUITE 400. Address of the SLEEP CENTER: RIDGEVIEW MEDICAL PLACE (See map in packet (on the north side of the hospital) 490 South Maple St., Suite 103 for both Waconia, MN 55387 building locations) Parking: Park in the area marked Entrance. The entrance doors will be locked when you arrive. YOU MUST RING THE BUZZER TO NOTIFY THE STAFF OF YOUR ARRIVAL. The sleep technician will then greet you at the front door and escort you to your private room in the Sleep Center. If you have been scheduled for a home sleep test, please read the following information, which will explain what is involved with the procedure. Benefits/Limitations of a Home Sleep Test While a Home Sleep Test (HST) offers the benefit of performing the test from your home, a HST is not indicated for every patient that may have a sleep disorder as it actually does not measure sleep. The Home Sleep Test is specifically indicated for patients that are at a high risk for a condition known as Obstructive Sleep Apnea (OSA). OSA is a condition characterized by loud snoring, excessive tiredness and repetitive breathing pauses. HST uses a limited number of sensors to detect this condition and is unable to detect any other sleep disorders. At times, sensors may become dislodged while you sleep resulting in inadequate recordings. Traditionally, these patients have been tested by complete laboratory testing, where a technologist monitors for all sleep disorders, assures that all of the recording equipment functions correctly and begins treatment as directed by a physician. In some cases, you may require complete laboratory sleep testing if one of the following occurs: The HST results are in normal ranges, but your symptoms suggest otherwise. If you have difficulty with treatments that are prescribed following the HST. Additional Sleep Disorders are suspected. If you have any questions or concerns about the testing procedure, feel free to call the Sleep Center at 952-442-8080. If no one is available, please leave a message and we will return your call. If you should need to cancel or reschedule your sleep study, please contact our scheduling office as soon as possible at 952-442-8012 from 8am-4:30pm. 15095 2/18 (side 1)

Information about the testing procedure When you arrive at the Sleep Center for your appointment, the technologist will instruct you on how to apply several recording sensors connected to a portable data recorder that will be used from the comfort of your own home. The accuracy of the test can be affected by where you apply the recording sensors or if they become dislodged during the test so it is important that you ask any questions you may have during the instruction period. An instruction sheet is provided to show you where the electrodes are to be placed and the Sleep Center Technologists are available throughout the night to assist you if issues arise with the device. Please contact them at 952-442-8080 if you feel you need assistance. The technologist will show you how to place a sensor that will be used to record your breathing pattern. Two elastic bands will be placed around your chest and abdomen to record your breathing effort. Next, a sensor will be placed over one fingernail so we ask that you have one finger (non-pinky) on each hand free of fingernail polish and/or acrylic nails. Finally, three electrodes will be placed on your chest to record your heart rate. The sensors and bands do not hurt, but initially may be distracting. During the recording, the sensors will be connected to a recording box attached to your shirt. You will be able to get up and use the bathroom if needed during the test. After completing the test, you will need to return the device to the sleep center within 24 hours so that we are able to download and review the recordings for interpretation. You will schedule a follow-up appointment with the sleep specialist to receive the results. On the day of your scheduled sleep study: Avoid naps Avoid caffeine after 10 a.m. (beverages and chocolate) Avoid alcohol If you have a cold, please contact us. We may want to reschedule your sleep test. Plan to bring the recording device back the day following your test. Address of the Sleep Center: Ridgeview Medical Place, 490 S Maple Street, Suite 103, Waconia, MN 55387 The entrance doors will be locked when you arrive. YOU MUST RING THE BUZZER TO NOTIFY THE STAFF OF YOUR ARRIVAL. The sleep technologist will then greet you at the front door and escort you to the Sleep Center to provide instructions on the use of the recording equipment. NOTE: You will receive two separate bills related to your visit to the Sleep Center - one from Ridgeview Medical Center for the home sleep test itself and one from Ridgeview Clinics for Dr. Vaela s professional interpretation of the test. If you have any questions, please do not hesitate to ask the sleep staff. 15095 2/18 (side 2)

Ridgeview Medical Place Ridgeview Medical Center Main Entrance STATE HIGHWAY 5 N Street South Maple Ridgeview Parking 5th Street West Parking lot Ridgeview Parking Ridgeview Professional Building Lakeview Clinic Lakeview Entrances and Parking Ring Door Bell to Enter Here Emergency Entrances FOLLOW-UP APPOINTMENTS IN THIS BUILDING Park Here Home Care & Hospice/ Home Medical Equipment Human Resources Street South Cherry 15098 2/18

Name _ Pulmonary & Sleep Medical Information Date of Birth or Patient Label Age: Ht. Wt. Address: Phone #: Referring Provider/Location: Primary Care Provider/Location: Instructions: Please complete as much as possible of the information requested below before coming to your appointment. This information is, and will be kept, strictly confidential. It will help your physician understand all your medical problems and prior history better, which is essential to providing good medical care. Reason for visit: PAST MEDICAL HISTORY: Please indicate if you have been diagnosed as having any of the illnesses below in the past year. Enter approximate year of initial diagnosis if you remember. Illnesses you have that are not listed may be entered in empty spaces. Yes No Year Yes No Year Yes No Year Diabetes Hay Fever Osteoporosis High Blood Pressure Heart Attack Stroke Emphysema Angina (Chest Pains) Blood Clots (legs or lung) Chronic Bronchitis Angioplasty Ulcers (stomach or duodenal) Asthma Heart Failure Cancer (enter organ below) Tuberculosis Thyroid Disease Seizure Past Surgical History: List all previous surgeries and year done. Allergies: Please list allergies to any medications. If you are allergic to X-ray contrast, please indicate so also. Pets/Birds: Medication List (or attach Medication List): Smoking History: Packs per day? How many years? Quit (year): Alcohol Consumption: Alcoholic drinks per day? What type? Caffeine Consumption: How much per day? What type? Family History: Please indicate if the illnesses below are present in your immediate family (parents, brothers or sisters). Illness X Relative affected Diabetes High Blood Pressure Heart Disease Cancer Illness X Relative affected Emphysema Asthma Hay Fever Tuberculosis Occupational History: What type of work do you currently do? Have you worked with asbestos, silica or coal in the past? When? Immunizations: Flu Vaccine? Pneumonia Vaccine? #15078 3/18 (side 1) OVER

Place a checkmark if you are bothered by any of the following symptoms frequently or constantly: Yes No Physician's Comments: Constitutional Fever?... Weight loss or weight gain?... ENT Congestion of nose?... Frequent "runny" nose?... Post nasal drip?... Hoarseness?... Pulmonary/Sleep Wheezing?... Shortness of breath at rest?... Shortness of breath with activities?... Cough?... Sputum or phlegm production?... Snoring?... Sleepy during the day?... Cardiac/Vascular Chest pain with exertion?... Leg cramps with walking?... GI Nausea and/or vomiting?... Frequent heartburn?... Bloody or tarry stools?... Change in bowel habits?... GU Up frequently at night to urinate?... Trouble urinating?... Muscular/Skeletal Pain in joints or elsewhere keeping you from sleeping?... Neurologic Frequent headaches?... Sudden loss of vision?... Blood/Lymph Easy bruising?... Enlarged lymph nodes?... Below for Physician's use only. Other symptoms are negative?... Reviewing Physician's signature Date #15078 3/18 (side 2)

Please complete the questions below as accurately as possible. When appropriate, fill in blanks, check, underline or circle best answer. 1. If you are currently employed, what shift do you work? [ ] 1st [ ] 2nd [ ] 3rd [ ] Rotating 2. What time do you go to sleep? 3. What time do you wake up? 4. How many times do you awaken during your sleep? Why? 5. Do you feel rested when awakening? [ ] Yes [ ] No 6. Do you nap during the day? [ ] Yes [ ] No 7. If you do nap, estimate frequency: [ ] daily times per week [ ] rarely 8. If you do nap, how long is your typical nap? 9. Do you perspire during sleep? [ ] Yes [ ] No 10. Do you snore? [ ] Yes [ ] No 11. Has your bed partner ever said you stop breathing during sleep? [ ] Yes [ ] No 12. Do you ever awaken from sleep gasping for breath or choking? [ ] Yes [ ] No 13. Do you often feel sleepy during the day? [ ] Yes [ ] No 14. Have you ever fallen asleep driving a vehicle (or nearly so)? [ ] Yes [ ] No 15. Ever had a car or work accident because of sleepiness? [ ] Yes [ ] No 16. Do you fall asleep easily during quiet activities (reading, TV, etc.)? [ ] Yes [ ] No 17. Are you often tired during the day? [ ] Yes [ ] No 18. Is your sleep restless? [ ] Yes [ ] No 19. Have you ever had a sudden irresistible sleep attack? [ ] Yes [ ] No 20. Do you ever suddenly feel very weak when laughing, sad, angry or otherwise excited (in the knees, neck, arms or all over)? [ ] Yes [ ] No 21. Do you ever feel you cannot move (for a brief period) just as you are falling asleep or when awakening? [ ] Yes [ ] No 22. Do you think you hallucinate when falling asleep or awakening? [ ] Yes [ ] No 23. Do you often experience confusion or poor memory during the day because you are too sleepy or tired? [ ] Yes [ ] No Ridgeview Sleep Disorders Center DAYTIME SLEEPINESS QUESTIONNAIRE #15067 1/2007 (Side 1) OVER

Name Age: Gender: [ ] Male [ ] Female Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing Situation Sitting and reading 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 Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Chance of Dozing TOTAL Thank you for your cooperation. Ridgeview Sleep Disorders Center DAYTIME SLEEPINESS QUESTIONNAIRE #15067 1/2007 (Side 2)

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