Sleep Center of Willmar LLC 1801 19 th Avenue South West Willmar, MN. 56201 320-441-2104 (telephone) 320-441-2052 (facsimile) Welcome Our staff understands that quality care and patient comfort go hand in hand. Please inform us in advance if you have any special needs (i.e. wheelchair access, require a personal care attendant, interpreter, extra blankets, fan, etc.) or if we can make your visit more comfortable in any way. We also understand the importance of follow-up care. Treating sleep disorders is often simple, yet many patients still require ongoing assistance. At Sleep Center of Willmar, we will be with you every step of the way from diagnosis through treatment and beyond. We are honored to serve your sleep care needs. Cancellation and No Show Policy: If you are unable to attend your scheduled sleep study, or need to reschedule, we require at least a 48 hour notice. If you do not notify us at least 48 hours in advance of your study you may be subject to a $150 fee. A no show is someone who misses a scheduled sleep study without cancelling at least 48 hours in advance. Failure to present to your scheduled sleep study will be recorded as a no show and will be subject to a $150 fee.
2 Your Study Please read the following information carefully. If you have any questions feel free to call us at 320-441-2104 You are scheduled to have a diagnostic test performed to check for sleep disorders, per your physician. When you arrive at the sleep center the technologist will greet you. The technologist will show you to your room, and be your contact throughout the night. Prior to testing, the technician will explain the procedure and answer any questions you may have. Please bring loose fitting clothing in 2 pieces such as a t-shirt and shorts, or a pajama set. o o Men: If you do not have a loose fitting pair of shorts, please bring boxer shorts. Women: For your convenience, please do not wear nightgowns, as they can make it difficult to connect some of our electrodes. Please shower and wash your hair before coming. Do not use any styling products in your hair. Do not wear perfumes or colognes Please remove any facial make-up or creams Please have a clean shaven face (no stubble) unless your normally wear a beard or mustache If you generally require special assistance during the night, we must be notified in advance. Our technician cannot provide physical assistance during your stay. Leave all valuables at home. We are not liable for lost valuables during your stay. Please bring your driver s license or state ID card and your health insurance card to your study. Frequently Asked Questions: What is a sleep study? A sleep study known as a polysomnogram, or PSG, is a diagnostic test used to identify different stages of sleep and classify various sleep problems. Why do I need a sleep study? The study was ordered by your physician, and is needed to determine various brain activities and body systems, and their relationship throughout your sleep period. After the study, a physician, specializing in sleep medicine, will review and interpret the information to help you, and your physician, understand your specific sleep patterns. If a sleep disorder is present, treatment recommendations will be made. What to expect?
Throughout the testing process, the technician will be recording many things. (I.e. limb movements, heart rate, brain waves, and respiratory rate) This is achieved by placing wires and electrodes on your body that will electronically relay the information to a computer that is observed by the attending technician. If the technician observes any issues with your breathing (sleep apnea) they may enter room to awaken you and place a device on you to correct the issue (CPAP) What happens after my sleep study? To best understand the results of your sleep study and any treatment recommendations made, it is important to meet with a sleep specialist in person. In some instances additional procedures are needed in order to establish the correct diagnosis or to evaluate a treatment. You will be informed if this is the case. Insurance and Billing Information: Talking to Your Insurance Company: We know understanding your healthcare benefits information is difficult and sometimes confusing. We highly recommend contacting your insurance provider prior to your appointment. They can assist you in explaining your specific benefit plan. 3 Sleep Hygiene Guidelines: Sleep Center s recommend the following sleep hygiene guidelines to assist you in achieving better sleep: Avoid Reading, watching TV, eating, listening to the radio etc. in bed. o The bed is to be used for sleep and sexual activity only. Minimize Noise, light and temperature extremes during the sleep period using earplugs, window blinds, and an electric blanket or air conditioner. o Both noise and light have been shown to disrupt falling asleep. o Temperatures either too hot or too cold (above 75 or below 54 degrees) can affect your sleep. Try not to drink fluids after 8:00 P.M. o This may reduce awakenings due to the need for urination during the evening Nicotine is a stimulant and should be avoided near bedtime and upon night awakenings. o We are not recommending smoking. If you must smoke, follow these suggestions; cut back before bed, have fewer cigarettes for the 4 hours before going to bed, and none 30-45 minutes before bed. Nicotine is a stimulant and should be discontinued 4-6 hours before bedtime.
4 Caffeine is in coffee (100-200 mg) soda (50-75mg), iced tea, chocolate, and various over the counter medications. o Caffeine stays in your system for up to 12 hours. Therefore we recommend avoiding caffeine past lunchtime and decaffeinated coffee or drinks after dinner. o Cutting back on caffeine intake often results in headaches that may affect your sleep. These symptoms are temporary as your body adjusts to the missing stimulant. Alcohol is a depressant; although it may help you fall asleep, it causes awakenings later in the night. o As alcohol is digested your body goes into withdrawal from the alcohol causing nighttime awakenings and often nightmares. A heavy meal too close to bedtime interferes with sleep (but a light snack may be sleep inducing). o Stay away from protein and stick to carbohydrates or dairy products except milk. o Milk that contains the amino acid L-tryptophan has been shown in research to help fall asleep. Do not exercise vigorously just before bed.
Sleep Center of Willmar LLC PATIENT INFORMATION FORM Name: Address: Date: Email: City: State: Zip: SSN: Home Ph: Cell Phone: Work Ph: Date of Birth: Age: Gender: Male / Female Primary Care Physician: Clinic: Phone: Referring Physician (if different): Clinic: Phone: Emergency Contact: Relationship: Phone Number: Current Work Status: Employed Full-Time: [ ] Part-Time: [ ] Student: [ ] Retired: [ ] Employer (if applicable): Primary Insurance Company: Policy #: Group # Primary Holder s Name: Relationship to Patient: Primary s Date of Birth: Secondary Insurance Company: Policy #: Group #: Primary Holder s Name: Relationship to Patient: Primary s Date of Birth:
Sleep Center of Willmar LLC No Do you snore? Do you have morning headaches? Are you usually tired during the day? Have you ever been told that you stop breathing while you sleep? Do you have high blood pressure? Is your neck size over 17 inches (male) or 16 inches (female)? YES Name: DOB: Phone: Primary Care Physician:
Sleep Center of Willmar LLC 1801 19 th Avenue South West Willmar, MN. 56201 320-441-2104 (telephone) 320-441-2052 (facsimile) Sleep Study Questionnaire Name: Sex: Male Female Address: City/State/Zip Telephone: Home ( ) Work: ( ) Mobile: ( ) DOB: Age: Height: What is (or was) your body weight: A. Now B. When age 20 C. When heaviest ever Occupation: Insurance Company: Policy # Group# Policy Holder Name: Policy Holder Date of Birth: Emergency Contact Information: Name: Relationship: Telephone #:
2 Sleep History: 1. Please describe your sleep problem that led your physician to order this study: 2. How long have you had this problem? 3. Has anyone else told you that you snore loudly? Yes No If yes, has your snoring caused people to refuse Yes No to sleep in the same room? 4. Has anyone noticed you to stop breathing in your sleep? Yes No How frequently? 5. Please indicate if you have noticed (or someone has told you) that you: A. Suddenly wake up gasping for breath or short of breath Yes No B. Wake up with a morning headache Yes No C. Snort yourself awake Yes No D. Notice your legs jerking or twitching during the night Yes No E. Are unable to move when falling asleep or immediately upon waking Yes No F. Have episodes of sudden muscular weakness (paralysis or inability to move) when laughing, angry or in other emotional situations Yes No G. Wake up confused and wander during the night Yes No Daytime Functioning: 1. Do you have a problem with severe sleepiness (feeling very sleepy or struggling to stay awake) during the daytime? 2. Do you often have a problem with your performance at work because of sleepiness? 3. Have you ever had a car accident caused by your sleepiness (not due to drugs or alcohol)? Yes No Yes No Yes No 4. Have you ever had a near car accident (for example, driving off the road) because of sleepiness (not due to drugs or alcohol)? If yes, how many times? 5. Do you fall asleep without meaning to during the day? Yes No If yes, how many times during the average week?
3 6. At what time of day do you feel the most fatigued/sleepy? Sleep Habits: 1. Estimate how many hours of sleep you get? On an average night On a bad night 2. On average, what is your normal bedtime? On average, what time do you get out of bed in the morning? 4. How many naps do you take during the average week? per week How long is your average nap? 5. How long does it take you to fall asleep? On an average night On a bad night 6. How many nights during the average week do you lie in bed for at least 30 minutes either trying to fall asleep or trying to return to sleep? nights per week 7. How many times do you wake up during the night? On an average night On a bad night 8. Does your job require that you change shifts? Yes No If yes, please describe: 9. How much of the following do you consume during the average day? a. alcohol b. coffee(withcaffeine) c. tea(with caffeine) d. softdrinks(withcaffeine) e. cigarettes f. other tobacco products Medical History: Please check if you have ever had any of the following conditions: Asthma/ Bronchitis Chronic pain Congestive Heart Failure Coronary Artery Disease Frequent headaches High blood pressure Nasal Obstruction Panic or anxiety attacks Depression Problems with alcohol or drugs Emphysema Epilepsy or seizures Diabetes Sexual function problems Stroke Ulcer/heartburn Please list the name, dosage and method by which you take it (mouth, injection, patch, etc.), for all the medications you are now taking:
4 Please add any other information that you feel is important. Patient s Signature Date