HOME SLEEP STUDY - PATIENT QUESTIONNAIRE DATE: …snoring/sleep apnea questionnaire history of...
Transcript of HOME SLEEP STUDY - PATIENT QUESTIONNAIRE DATE: …snoring/sleep apnea questionnaire history of...
HOME SLEEP STUDY - PATIENT QUESTIONNAIRE DATE:
Who is the Physician ordering the Sleep Study?
Who is the primary care Physician?
Do you want this report sent to another Physician?
PERSONAL INFORMATION
Patient’s Name: First: Middle Initial: Last: Sex: Male Female
Date of Birth: Email: Age
Home Address: Home Phone #:
Cell Phone #:
Work Phone #:
Place of Employment: Occupation: Weight: lbs. Height: ft in
EMERGENCY CONTACT PERSON:
Name: Relationship: Home Phone #: Cell Phone #:
INSURANCE INFORMATION
Primary Insurance:
Secondary Insurance:
(Complete only if you are not the Insurance Policy Holder)
Policy Holder Name: First: Middle Initial: Last:
Relationship:
Policy Holder’s Address:
Policy Holder’s Date of Birth:
City:
State:
ZIP Code:
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You have two options for completing a questionnaire:- Enter the information on the fillable PDF and click ‘Print’ at the end of the document - Print the questionnaire and fill it out by hand
The Authorization Signature must be completed by hand.Please bring the completed questionnaire(s) to the office or sleep lab.
AUTHORIZATION
I authorize the release of any medical information necessary to process my insurance claim, and authorize payment of medical benefits to the facility and providers for services rendered. I am aware that payment of insurance copay/deductible is patient responsibility. If necessary, I also authorize release of medical information to durable medical equipment providers and referring/primary care providers involved in my care. I authorize the use of audio and video monitoring as part of my sleep study. I understand that the copay / deductible is my responsibility. I am also aware that the Sound aSleep Sleep Diagnostic Lab facility is owned and operated by Narendra R.Kumar,M.D,P.C
Sign: Date:
SNORING/SLEEP APNEA QUESTIONNAIRE
HISTORY OF SNORING Yes No
HAVE YOU BEEN TOLD THAT YOU STOP BREATHING DURING SLEEP Yes No
RESTLESS / UNREFRESHED SLEEP Yes No
RESTLESS LEGS Yes No
DAYTIME SLEEPINESS / NAP Yes No
DAYTIME FATIGUE/ LACK OF ENERGY Yes No
HISTORY OF MEMORY LOSS Yes No
DIFFICULTY TO CONCENTRATE Yes No
DO YOU FEEL IRRITABLE/CRABBY Yes No
DO YOU SUFFER FROM DIMINISHED SEXUAL DRIVE? Yes No
DO YOU WAKE UP FROM SLEEP? Yes No
DO YOU SUFFER FROM INSOMNIA/DIFFICULTY SLEEPING Yes No
DO YOU SUFFER FROM DEPRESSION Yes No
HISTORY OF HEART DISEASE, HEART FAILURE, ATRIAL FIB Yes No
DO YOU HAVE PACEMAKER/ DEFIBRILLATOR Yes No
HISTORY OF STROKE, TIA, MUSCLE WEKNESS, MS, ALS Yes No
HISTORY OF HYPERTENSION Yes No
HISTORY OF FIBROMYALGIA, CHRONIC FATIGUE Yes No
UNEXPLAINED WEIGHT GAIN? Yes No
HAVE YOU HAD PREVIOUS SLEEP STUDY? Yes No
HAVE YOU USED CPAP IN THE PAST? Yes No
THE STOP QUESTIONNAIRE
1. Do you SNORE loudly? Yes No
2. Do you often feel TIRED, fatigued, or sleepy? Yes No
3. Have you been OBSERVED to stop breathing during sleep? Yes No
4. Are you being treated for high blood PRESSURE? Yes No
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EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't 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 (eg, a theater or meeting) 0 1 2 3
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
Please bring this completed form (with signature) and also your insurance card when you come to the office / sleep lab.
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