Jameel Durrani, MD FCCP FAASM 327 main Street, Suite 2...
1
Jameel Durrani, MD FCCP FAASM 327 main Street, Suite 2 Emmaus, PA 18049 Phone 610-966-9667 | Fax 610-966-9660 Sleep Medicine History Form Yes Don't Know No Do you snore? If yes, is it affecting your cohabitation (spouse complaints)? No Yes Are you a restless sleeper? No Yes No Yes No Yes Shift worker? Night Day Mixed If Yes, which shift? No Yes No Yes No Yes If checked, please tell us about your sleep patterns Check here if you sleep and wake up at odd times. How much time does it take you to fall asleep? How many times? Weekdays: Time to bed? How many of coffee, caffeine, soda do you drink daily? Wake up at? Weekends: Time to bed? DAYTIME NAPS Dur.? Wake up at? Pets in bedroom? TV in bedroom? Find out now if your daytime sleepiness is excessive. It's easy. The Epworth Sleepiness Scale (ESS) has 8 routine daytime situations that you can rate on a scale of 0 - 3 based on your likelihood of dozing off or falling asleep in each situation. Circle the applicable # No Yes Do you routinely wake up at night? No Yes Difficulty falling back to sleep: No Yes No Yes Visible clock in bedroom 0 = Would never doze 1 = Slight chance of dozing 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 Sitting and reading As a passenger in a car for an hour with no break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch without alcohol In a car while stopped for a few min. in traffic Sitting inactive in a public place (theater/mtg.) Watching TV Situation Chance of Dozing No Yes BEDROOM ENVIRONMENT THE EPWORTH SLEEPINESS SCALE PATIENT INFORMATION SLEEP SYMPTOMS SLEEP TIMINGS Feel better after the nap? Do you take daytime naps? Do you feel tired or fatigued during the daytime? Dose off watching TV, or reading a book? Fight off drowsiness while driving? Any near misses or accidents? Did you ever drive to a place, and have no recall of how you got there? In emotional situations (angry/laughing out loud) do you feel any weakness in your legs or actually fall down? Do you often forget what you were doing in the middle of something (ie Enter a room, and forget why you are there)? No Yes No Yes DAYTIME WAKEFULNESS Date of Birth Last Name MI First Name Have you ever had a sleep study before? Are you currently using CPAP on a nightly basis? : Current CPAP pressure? : Yes No Yes No Sometimes If Yes, when? Where? Cm. No Yes No Yes No Yes Do you frequently drop things(ordinary objects like glass, files, keys etc)? No Yes OTHER DAYTIME SYMPTOMS Do you often notice any cramps, creeping or crawling sensations in your legs in the evening or when you go to bed? If Yes, do these sensations get better if you take a walk, or stretch your legs? If Yes, do these sensations make it difficult to sleep? EVENING SYMPTOMS DREAM HISTORY Has anybody noticed you to have pauses in your breathing? Has anybody noticed you choking/grunting while asleep? Do you usually have have dry mouth on waking up in AM? Do you usually have have headache on waking up in AM 2 = Moderate chance of dozing 3 = High chance of dozing No Yes Do all dreams have the similar content? No Yes Do you recall your dream content? Do your dreams mix with wakefulness? Do you find yourself acting out your dreams at times?, (ie jumping out of bed, punching the wall, etc): No Yes Do you feel you dream excessively? Yes No Yes No No Yes Yes No Yes No Is there anything else you would like your physician to know about your sleep pattern? Date GENERAL SLEEP TIMINGS Yes No No Yes No Yes No Yes
Transcript of Jameel Durrani, MD FCCP FAASM 327 main Street, Suite 2...
Jameel Durrani, MD FCCP FAASM 327 main Street, Suite 2 Emmaus, PA 18049
Phone 610-966-9667 | Fax 610-966-9660Sleep Medicine History Form
Yes Don't KnowNoDo you snore?If yes, is it affecting your cohabitation (spouse complaints)? NoYes
Are you a restless sleeper?
NoYesNoYes
NoYes Shift worker?NightDay MixedIf Yes, which shift?
NoYes
NoYesNoYes
If checked, please tell us about your sleep patternsCheck here if you sleep and wake up at odd times.
How much time does it take you to fall asleep?
How many times?
Weekdays: Time to bed?
How many of coffee, caffeine, soda do you drink daily?
Wake up at?Weekends: Time to bed?
DAYTIME NAPSDur.?
Wake up at?
Pets in bedroom?TV in bedroom?
Find out now if your daytime sleepiness is excessive.It's easy. The Epworth Sleepiness Scale (ESS) has 8 routine daytime situations that you can rate on a scale of 0 - 3 based on your likelihood of dozing off or falling asleep in each situation. Circle the applicable #
NoYes
Do you routinely wake up at night? NoYes
Difficulty falling back to sleep:
NoYesNoYesVisible clock in bedroom
0 = Would never doze1 = Slight chance of dozing
1 2 31 2 31 2 31 2 31 2 31 2 31 2 31 2 3
Sitting and reading
As a passenger in a car for an hour with no breakLying down to rest in the afternoonSitting and talking to someoneSitting quietly after lunch without alcoholIn a car while stopped for a few min. in traffic
Sitting inactive in a public place (theater/mtg.)Watching TV
Situation Chance of Dozing
NoYes
BEDROOM ENVIRONMENT
THE EPWORTH SLEEPINESS SCALE
PATIENT INFORMATION
SLEEP SYMPTOMS SLEEP TIMINGS
Feel better after the nap?Do you take daytime naps?
Do you feel tired or fatigued during the daytime?Dose off watching TV, or reading a book?Fight off drowsiness while driving?Any near misses or accidents?
Did you ever drive to a place, and have no recall of how you got there?In emotional situations (angry/laughing out loud) do you feel any weakness in your legs or actually fall down?Do you often forget what you were doing in the middle of something (ie Enter a room, and forget why you are there)?
NoYesNoYes
DAYTIME WAKEFULNESS
Date of Birth Last Name MI First Name
Have you ever had a sleep study before?
Are you currently using CPAP on a nightly basis? : Current CPAP pressure? :
Yes No
Yes No Sometimes
If Yes, when? Where?
Cm.
NoYesNoYesNoYes
Do you frequently drop things(ordinary objects like glass, files, keys etc)? NoYes
OTHER DAYTIME SYMPTOMS
Do you often notice any cramps, creeping or crawling sensations in your legs in the evening or when you go to bed?If Yes, do these sensations get better if you take a walk, or stretch your legs?If Yes, do these sensations make it difficult to sleep?
EVENING SYMPTOMS
DREAM HISTORY
Has anybody noticed you to have pauses in your breathing?Has anybody noticed you choking/grunting while asleep?Do you usually have have dry mouth on waking up in AM? Do you usually have have headache on waking up in AM
2 = Moderate chance of dozing3 = High chance of dozing
NoYesDo all dreams have the similar content?
NoYesDo you recall your dream content?Do your dreams mix with wakefulness?
Do you find yourself acting out your dreams at times?, (ie jumping out of bed, punching the wall, etc):
NoYesDo you feel you dream excessively?
Yes No
Yes NoNoYes
Yes No
Yes No
Is there anything else you would like your physician to know about your sleep pattern?
Date
GENERAL SLEEP TIMINGS
Yes No
NoYes
NoYes
NoYes
