Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all medications with you to your first appointment. Please call 410-641-1100 ext. 5118 to confirm your appointment. Appointment Date: Time: Name: Last First MI Home Phone # Cell # Work # DOB: SS # Gender: Height: Weight: BMI: Address: _ Appt # P.O Box Emergency Contact and phone# Occupation: Shift Work: YES NO. If YES, what are your hours? Referring Physician: Address: Phone # Primary Physician: Address: Phone # Primary insurance company:_ Address Policy# Group# Guarantor name: Birth date: Secondary insurance company: Address
Policy# Group# Guarantor name: Birth date: Sleep History: Please circle all that apply: Daytime Sleepiness Trouble Concentrating Dozed while driving Memory Loss Snoring Gasping Choking Restless Sleep Shortness of Breath Difficulty getting to sleep Teeth Grinding Periods of waking up (how many ) Insomnia Anxiety Pain Restless Legs Irritable Depressed Mood Swings Sweating Frequent Urination (how often ) Vivid Dreams Nightmares Sleep Talking Sleep Walking Yelling out Do you wake in the morning with a headache, sore throat, dry mouth, or confusion? Waking with the feeling of paralysis in arms or legs or while laughing, excited, or coughing. Please explain: How long have you had these symptoms? Do you nap during the day?.for how long? Do you feel refreshed after a short (10 to 15 minute) nap? Did you nap today? For how long? What time?_
Do you fall asleep without notice, during conversations, driving etc.? Does your sleepiness occur in intervals during the day? Around what time of the day do you feel most tired? What position do you normally sleep in? How long does it take you to function at a normal level in the morning? Do you use caffeine or over the counter medication to stay awake during the day? Please list: How often? _ Do you use sleep aids to fall asleep? How often? How long have you been taking sleep aids? Please list: Do you use alcohol before bed? How often? During the day? How often? Medical History: Family History of sleep apnea or any other sleep disorder, please explain: Please circle all that apply: High blood pressure Heart disease Defibrillator Pace maker Stints
Heart attack Chest Pain Stroke Seizures Diabetes Kidney disease Dialysis ED Decreased sexual interest Shortness of breath COPD Lung disease Fibromyalgia Swelling in ankles, feet, lower legs Deviated septum Seasonal allergies Have you been diagnosed with sleep apnea before? If yes When? Where?_ Do you use CPAP therapy at home? What pressure is your CPAP machine set on?_ If you do not wear your CPAP at night please state why: Arthritis, in what areas: Any psychiatric diagnoses: Head injury, please explain:_ Weight gain of lbs. Since.Weight loss of lbs. Since. Explanations and/or other medical history not listed: Please list all medications with dose, how often, reason:
Please list all surgeries with dates including tonsils and adenoids : Please use the following scale to choose the most appropriate number for each situation. Epworth Sleepiness Scale: 0= 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 public As a passenger in a car for 1hour Lying down in the afternoon to rest Sitting and talking to someone Stopped for a few minutes in traffic Chance of dozing TOTAL