SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License: Marital Status: Single Married Divorced Widowed Email address: Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax: Primary Insurance Information Carrier: Policy #: Group: Carrier Social Security Number: Secondary Insurance Information Carrier: Policy #: Group #: Carrier Social Security Number:
SUNSET SLEEP LABS SLEEP HISTORY QUESTIONNAIRE Name: Date: Age: Occupation: Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. My Main Sleep Complaint(s) Is: being sleepy all day snoring difficulty falling asleep difficulty remaining asleep awaken too early breathing or snoring stops for brief periods awaken gasping for breath unwanted behaviors during sleep, explain other explain Sleep treatment I was previously diagnosed with: sleep apnea When? Where? My prior treatment included CPAP, pressure if known cm Bilevel or BiPAP, pressure if known cm Oral appliance Sinus, deviated septum or turbinate reduction Uvulopalatopharyngoplasty (UPPP) Laser or other procedure with uvula Tonsils and/or adenoidectomy Other I was previously diagnosed by a physician with: Restless Legs Syndrome When? Where? Periodic Limb Movements When? Where? Narcolepsy When? Where? Insomnia When? Where? 1
Symptoms during sleep: Name: On average how often do you experience the following symptoms when sleeping or trying to sleep? Never Occasionally Frequently Always SYMPTOM My mind races with many thoughts when I try to sleep I often worry whether or not I will be able to fall asleep Fatigue Anxiety Memory Impairment Inability to concentrate Awaken with dry mouth Morning headaches Pain which delays or prevents my sleep Pain which awakens me from sleep Vivid or lifelike visions (people in room) as you fall asleep Vivid or lifelike visions as you wake up Sudden weakness or feel your body go limp when angry or excited Irresistible urge to move legs or arms Creeping or crawling sensation in you legs before falling asleep Legs or arms jerking during sleep Sleep talking Sleep walking Nightmares Fall out of bed Heartburn, regurgitation, or indigestion which disrupts sleep Bed wetting Frequent urination disrupting sleep Teeth grinding Wheezing or cough disrupting sleep Sinus trouble, nasal congestion or post-nasal drip interfering sleep Shortness of breath disrupting sleep Depression 2
Name: Sleep Habits: Please answer the following questions as accurately as possible. Indicate a.m. and p.m.. If your work and/or sleep schedule changes during the week then indicate your schedule using the shift work column. Activity Usual Schedule Weekends Shift Work The time I usually go to bed I usually fall asleep in (minutes, hours) How many times do you awaken each night? Number of times I have difficulty returning to sleep? The total time I spend awake in bed The time I usually wake from sleep The time I usually get out of bed On average I get hours of sleep per night Do you take naps? If so, for how long? Begin work time End work time If you do rotating shift work, or have other work schedule changes and need more space to describe: Medical History Please check if you have had any of the following: Heart disease, type Diabetes High blood pressure Depression Asthma/Emphysema Reflux Thyroid condition Fibromialgia Anxiety Seizures Parkinson s disease Stroke Head injury or Brain surgery Pain which disrupts sleep, area Other medical problems What is your current: Weight? Height? Have you gained weight in the last 5 years? How much? Have you lost weight in the last 5 years? How much? What is your neck circumference? Inches 3
Name: Social History (please answer by circling bold type) Do you smoke? Yes No Did you previously smoke? Yes No If yes, how many years? How much per day? Do you drink alcohol? Yes No If yes, how much? drinks per day / week / month What do you usually do at work? Do you drink caffeinated beverages? Coffee Tea Cola. How much daily? Please describe any exercise you perform beyond what you do at work or ordinary activities. Environment (please answer by circling bold type) Is your bedroom quiet / loud and light / dark? Is your mattress soft / hard / just right? Do you go to sleep with the TV. on? Yes No Is your sleep disturbed because of your bed partner or others in your household (children/pets)? Yes No Medication: Please list any medication you routinely take, including prescription and over the counter. MEDICATION AMOUNT TIME See attached (please use a separate sheet if more room is needed) Do you take anything to help you sleep? Yes No If yes, what? How often? Are you on supplemental oxygen? Yes No If yes, how much? (liters/min) Family History: Please check all that apply Is there a family Restless Legs Other sleep Apnea Snoring Narcolepsy Insomnia history of: Syndrome disturbances Father Mother Sister Brother Grandparents Children 4
SUNSET SLEEP LABS THE 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 Chance of Dozing Sitting and reading 0 1 2 3 Watching TV 0 1 2 3 Sitting inactive in a public place 0 1 2 3 (e.g. a theater or meeting) As a passenger in a car of an hour without a break 0 1 2 3 Lying down to rest in the afternoon when Circumstances permit 0 1 2 3 Sitting and talking to someone 0 1 2 3 Sitting quietly after a lunch without alcohol 0 1 2 3 In a car, while stopped for a few minutes in traffic 0 1 2 3 Total Score: A total score of 6 or more suggests daytime sleepiness. 10 or more suggests excessive daytime sleepiness (EDS). 16 or more suggests dangerously excessive daytime sleepiness.