Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married Divorced Widowed Separated Other Spouse Name: Spouse DOB: Spouse Employer: Emergency Contact Name: Phone #: Local Pharmacy Name and Location: Mail Order Pharmacy Name: INSURANCE INFORMATION Primary Insurance Company Subscriber Subscriber s DOB Secondary Insurance Company Subscriber Subscriber s DOB Tertiary Insurance Company Subscriber Subscriber s DOB Prescription Insurance Company ID: PHYSICIAN INFORMATION Primary Care Physician: Referred by: Other Physicians:
Page 2 of 7 PLEASE DESCRIBE YOUR MAIN COMPLAINT: PRIOR STUDIES AND TEST RESULTS (Facility Name and Location): PAST MEDICAL HISTORY (List diagnosis and date first diagnosed): NONE 1. 2. 3. 4. 5. 6. Have you ever been diagnosed with any of the following (Check beside proper diagnosis): Asthma COPD Emphysema Pulmonary Hypertension Interstitial Lung Disease Sarcoidosis Pulmonary Fibrosis Chronic Bronchitis Allergy Rhinitis Allergic Sinusitis Sinusitis Pneumonia Adult Respiratory Stress Pneumothorax Lung Cancer Syndrome Bronchiectasis Other Lung Disease Congestive Heart Failure Sleep Disorders Obstructive Sleep Apnea
Page 3 of 7 Past Surgical History (List all types of surgery, date, location): NONE 1. 2. 3. 4. Current Medications: NONE Medication Name Dosage How Many Times Per Day List over the counter medications/herbs/supplements: NONE 1. 2. 3. 4. DO YOU HAVE ALLERGIES TO: MEDICATIONS: NONE Name of medication you are allergic to: Type of reaction (rash, breathing problem, upset stomach)
Bar Ancillary Code #7680026 Profile Ancillary Profile Form Page #131003 4 of 7 (10/16) BHF Page 5 of 7 FOODS: NONE SEASONAL: NONE Do you use Oxygen at home? Yes, daytime and nighttime Yes, nighttime only Yes, only with exertion No If yes, how many liters) Year Oxygen was first prescribed: Do you use CPAP or BIPAP? Yes No (machine setting (cm/h2o) Year Prescribed FAMILY HISTORY: (Mother/Father/Siblings) Father: Living/Deceased Age Medical Problems Mother: Living/Deceased Age Medical Problems Total Number of Brothers Ages Medical Problems Total Number of Sisters Ages Medical Problems Total Number of Children Ages Medical Problems
Page 6 of 7 SOCIAL HISTORY: Occupation: Full Time Part Time Unemployed Disabled Student Other Pets (type and number): Do you smoke? Yes Packs per day No Previous Smoker Year quit Are you exposed to secondhand smoke? Yes No How much daily caffeine (coffee/tea/soft drinks)? Have you ever used marijuana, cocaine or other illicit drugs? Yes No If yes, which drug and how often Do you drink alcohol? ( beer wine liquor NONE) How many meals do you eat per day? Do you exercise regularly? Yes No If yes, how many times per week? Have you gained or lost weight in the last year? Yes No If yes, how many pounds lost or gained? SLEEP SCHEDULE Time you go to bed Time you get up Average amount of sleep per night Weekday Weekend How long does it take you to go to sleep? Do you function best in the Morning Afternoon Evening? Do you function worst in the Morning Afternoon Evening?
Page 7 of 7 SLEEP QUALITY QUESTIONNAIRE Do you have difficulty sleeping through the night? Do you feel tired and un-refreshed when you wake up? Do you snore? Do you have arm or leg movements during sleep? Have you even been told that you stop breathing during sleep? Do you ever wake up gasping or choking during sleep? Do you have early morning headaches? Is your sleep restless? Have you ever been told you have a sleep disorder? Do you feel that you have a sleep problem? Do you have a problem with excessive daytime sleepiness? Do you frequently fall asleep while watching TV? Do you tend to fall asleep during the day when you are quiet and inactive? Do you feel distracted and unable to concentrate during the day? Do you have difficulty staying awake to drive? Have you had any accidents at work due to sleepiness? Have you had an auto accident within the last 5 years? Have you been told that you snore loudly? Do you snore in all sleeping positions? Have you ever awakened at night with coughing or gasping for air? Do you awaken with a sore throat? Have you awakened at night with chest tightness or discomfort? Have you awakened at night with a sour taste in your mouth? Do you have sudden episodes of sleep during the day? Have you ever experienced periods in which you feel paralyzed while going to sleep, or waking up? Have you ever had visual hallucinations or dream-like mental images when falling to sleep? Did you have childhood sleep problems or any type? Do you take scheduled naps during the day? Do you feel better after short naps? Are you sleepy even on vacation? YES NO
Do you kick your legs at night? Do you have tingly sensations in your legs and you just have to move them? Do you have difficulty initiating sleep? Do you have frequent awakenings? Do you usually have restless sleep? Do you sleep better away from your own bed? (vacations, visiting family) Are you sleepy even when you increase your sleep time? Do you have pain that bothers you at night? Do you grind your teeth in your sleep? Have you ever had a severe head trauma? Do you sleep walk? Do you wet the bed at night? Do you talk in your sleep? Do you have frequent nightmares? Do you ever wake up screaming? Are you awake at night because of your bed partner? (noise or movement) Are you awake at night because some other person needs assistance? (infant or elderly) Do you have rotating or night shift work? YES NO 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: Situation Sitting and reading Watching TV Sitting inactive in a public place (theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score Chance of Dozing? 0= no chance of dozing 1= slight chance of dozing 2= moderate chance of dozing 3=high chance of dozing