Sleep Well Centers Patient Questionnaire

PATIENT REGISTRATION

Today's Date / MM / DD YYYY

Patient's full name:

Birth date / MM / DD YYYY

Email address

Address

Street address

Address line 2

City

State

Postal / Zip Code

Marital status Single Married Divorced Widowed

Child lives with (for minors only) Mother Father Both

May we leave a message at your home with other resident? Yes No

On your answering machine/voicemail? Yes No

Who may we talk to about your medical concerns

Is this contact for emergency purposes only? Yes No

Relationship

Relationship phone

Do you use CPAP or Oxygen at home? CPAP Oxygen at home No

If so, which home care company?

Primary insurance card holder's full name

Primary insurance company

Insurance contract number

Group number

Relationship to card holder Self Spouse Dependant

Card holder's name

Secondary insurance card holder's full name

Secondary insurance company

Secondary insurance contract number

Secondary insurance group number

Secondary insurance relationship to card holder Self Spouse Dependent

Identification of other physicians/health care providers involved with my medical care whom I authorize ongoing release of information for continuity of care: may we provide him/her with updated information Yes No

Referring Physician

Referring Physician phone

Primary Care Physician

Primary Care Physician phone

Type of Physician/health care provided

Patient Questionnaire

Height

Est. Current Weight
List all current medications including vitamins and herbal supplements
Do you have any allergies? Yes No
If yes, please list your allergies

Check all that apply to you

snoring/snorting

leg jerking

depression

acting out dreams

sleep walking

wake up to early

high cholesterol

can not move briefly upon awakening

chronic pain

stress

loss of muscle tone

difficulty falling asleep

sleep attacks

poor memory/concentration

difficulty staying asleep

sleep talking

fatigue excessive daytime sleepiness

morning headaches/migraines

panic attacks

frequent nocturnal urination

awaken frequently during the night

night sweats

frequently change body positions during the night

high blood pressure/hypertension

non-restorative sleep

legs feel sore/achy

stop breathing during sleep

seizures

teeth grinding

acid reflux/gerd

Do you wear oxygen? All the time Night time As needed for exercise No
How many liters per minute of oxygen do you use?
Do you have diabetes? Yes No
Is your diabetes controlled? Yes No
Are you claustrophobic? Yes No
Do you have a history of seizures or “spells”? Yes No
Do you have any other medical conditions which we have not listed?
Does anyone in your family have a known sleep disorder? Yes No
If yes, what is the sleep disorder?
How long do you sleep on a normal night?
What time do you go to bed normally?
What time do you get up normally?
Do you work swing shifts or night shifts?
On average, how many minutes does it take you to fall asleep?
On a normal day, do you have any of the following:
Caffeine? Yes No
If yes, how much caffeine?
Alcohol? Yes No
If yes, how much alcohol?
Nicotine? Yes No
If yes, how much nicotine?

Do you use or have you used within the last month, any recreational street drugs? Yes No

Do you have any physical complaints at this time? Yes No

Please list your physical complaints
Do you have any additional comments or concerns?
Do you require any special assistance we need to be aware of? (i.e. wheelchair, learning disability, difficulty communicating)

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is a questionnaire designed to evaluate levels of excessive sleepiness. This test is a standardized screening tool, used extensively by the American Association of Sleep Medicine (AASM), that will help you measure your general level of sleepiness. It asks you to rate the chances that you would doze off or fall asleep during different routine situations. Answers to the questions are rated as follows: Use the following scale to choose the most appropriate number for each situation:
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
Situation: Sitting and reading
Situation: Sitting inactive in a public place
Situation: Being a passenger in a motor vehicle for an hour or more
Situation: Lying down in the afternoon
Situation: Sitting and talking to someone
Situation: Sitting quietly after lunch (no alcohol)
Situation: Stopped for a few minutes in traffic while driving
Total score (add the scores up)(This is your Epworth score)
The Epworth Sleepiness Scale Key Total score of less than 9 suggests that you may not be suffering from excessive sleepiness.
A total score of 9 or more suggests that you may need further evaluation by a physician to determine the cause of your excessive sleepiness and whether you have an underlying sleep disorder. This sleepiness scale is intended to help you evaluate the extent of your sleepiness. Other factors may contribute to sleep disorders. This test is not intended to substitute for a medical assessment by your physician.
Thank you for your finished registration form, please click the Submit button.

I agree that any copays or deductibles will be paid at time of service.