PCCSS, LLP Pulmonary, Critical Care & Sleep Specialists

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NAME: AGE: DOB: DATE: REQUESTING PHYSICIAN: NOTE: Please help us find out about you by filling out the Patient side of this form on pages 1 3. If you don t know the answer to one of the questions, ask your bed partner if he/she can answer it for you. PLEASE LEAVE CLINICIAN SIDE BLANK. Why are you here to see a sleep specialist? Do you snore: Don t Know CC HPI If yes, is it loud? Don t Know How long ago did it start? Is it worsening? In which position do you snore? Back only All positions Is it worse on you back? Do you snore if you fall asleep in a chair? Does it disturb anyone? If yes, who? Has anyone ever noticed if you stop breathing in your sleep? Do you gasp or choke while you sleep? Do you suffer from either of the following in the morning? Dry mouth Headache

Do you feel sleepy during the daytime? Don t Know How many days per week? When did it start? Is it worsening? Don t Know How likely are you to doze off or fall asleep in the following situations? Please use the following scale: 1. Moderate chance of dozing 2. Slight chance of dozing 3. Moderate chance of dozing 4. High chance of dozing Sitting and reading EPWORTH SCORE: Watching television Sitting inactive in a public place While a passenger in a car without a break Laying 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 in traffic for a few minutes Are you being treated now or have been treated for any illness? PERSONAL, FAMILY, SOCIAL HISTORY 1. Past Med Hx 2. 3. 4. 5. Have you ever had any operations? Any injuries? Past Surg Hx 1. 2. 3. 4. 5. Check if any close family member has: Family Hx Heart problems Diabetes Heartburn High Blood Pressure Cancer Other:

Marital Status S M W D Social Hx With whom do you live? What is your occupation? What are your leisure activities? What is your education level? Please circle any symptom you have, so we can find more about it: REVIEW OF SYMPTOMS Lack of energy; daytime sleepiness, trouble sleeping; Constitutional Snoring; loss of appetite; weight changes; fevers Eye problems, such as double or blurred vision; glaucoma; HEENT cataracts Hearing problems; buzzing or ringing in ears Allergies; hay fever Sinus problems Blood pressure or heart problems Cardiac Asthma; tuberculosis Pulmonary Stomach problems; heartburn; indigestion; Gastrointestinal change in bowel habits Urinary problems; frequency, infections; stones; bladder Genito Urinary Men: Prostate problems; night time urination Women: Abnormal menstrual periods; breast lumps; Female Reproductive could you be pregnant; recent mammogram, pap smear or pelvic exam Joint pains, swelling or redness; arthritis; back pain Musculoskeletal Muscle aches or tenderness; gout Rash, itching or other skin problems Dermatologic Paralysis (even temporary); numbness; loss of balance; Neurologic Seizures; loss of memory; headaches; stroke; Unusual thoughts; nervousness; crying or sadness; Psychiatric Suicide attempts; depression Thyroid disorder; diabetes; excess thirst or hunger; Endocrinologic Frequent urination Bleeding; easy bruising; risk factors for HIV; anemia; cancer Hematologic Others: Personally reviewed by me. I agree with or have amended its findings. Physician Signature

PHYSICAL EXAMINATION BP PULSE SpO2 RESP T GENERAL APPEARANCE N=Normal A=Abnormal D=Deferred Description of Abnormal Findings 1) NOSE: Mucosa Turbinates Septum 2) MOUTH: Mucosa Teeth Gums Tongue Pallate: Hard Soft Tonsils Posterior Pharynx 3) NECK: Appearance Symmetry Tracheal Position Crepitus Thyroid JVD 4) RESPIRATORY: Inspect Symmetry Percussion Palpation Auscultation Effort 5) HEART: Apex Heave Thrill Sounds Murmur Rub 6) ABDOMEN: Masses Tenderness Liver Spleen Bowel Sounds 7) LYMPH: Neck Axilla Groin Other (Specify) 8) MUSCULOSKELETAL/ NEUROLOGIC: Gait Station Strength Atrophy Tone Abnormal Movement 9) EXTREMETIES: Varicosities Edema Pulses Temp Tenderness Digits Nails 10) SKIN: Scars Rashes Describe 11) NEUROPSYCH: Oriented Mood New Patient Office Consult 99201 1 5 Bullet Points 99241 99202 6 11 Bullet Points 99242 99203 12 17 Bullet Points 99243 99204 All Items with Gray Border and 1 99244 99205 Item in each non Gray Border 99245

MEDICAL DECISION MAKING DATA REVIEWED: Lab (Date) Hemoglobin Electrolytes Other (Specify) Pulmonary Function Test (Date) Bronchoscopy (Date) Other (List/Date) X Rays (Date) Physician Interpretation: Chest CT Chest MRI Other (List Type) IMPRESSION: PLAN: F/U PFT/Spirometry V/Q Scan Chest X ray Nocturnal Pulse Oximetry Bronchoscopy Lab Pulm Risk Reduction CPEX Level 1 Level 2 Other Physician Signature

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