Page 1 of 8. SLEEP DISORDERS CENTER QUESTIONNAIRE Swedish Medical Center. Name: Date: Height: Weight: Neck Size: Handedness: Right/Left.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Page 1 of 8. SLEEP DISORDERS CENTER QUESTIONNAIRE Swedish Medical Center. Name: Date: Height: Weight: Neck Size: Handedness: Right/Left."

Transcription

1 Page 1 of 8 SLEEP DISORDERS CENTER QUESTIONNAIRE Swedish Medical Center Name: Date: Date of Birth: Age: Sex: M F Height: Weight: Neck Size: Handedness: Right/Left Which physician evaluated you for your sleep problem? Name: Address: Phone #: Who is your Primary Care Physician? Same as above? Yes No If No fill in Primary Physician Below Name: Address: Phone #: PLEASE ANSWER THIS QUESTIONNAIRE WITH THE ASSISTANCE OF YOUR BED PARTNER CIRCLE ANSWERS OR FILL IN THE BLANKS AS INDICATED If you have filled out this same questionnaire for the Colorado Sleep Disorders Center at Swedish Medical Center within the last 6 months you may stop here

2 Page 2 of 8 1. What is your sleep problem? 2. What tests have been done for your sleep problem? 3. What have other doctors tried to help your sleep problem? 4. What have you tried for your sleep problem?

3 Page 3 of 8 1. List your current tobacco use (if none, write none): 2. List your alcohol use (if none, write none ): 3. List your caffeine use (if none, write none ): 4. Do you use oxygen? Yes No 5. Do you use CPAP or BiPAP? Yes No 6. If you use oxygen or CPAP or BiPAP list how much you use or the dose and when you use it (day, night, all the time, etc.): 7. List your present job & highest education level: 8. List your drug allergies: (if none write none ) Please list all your medications (include over-the-counter if none write none ) on the following sheet:

4 Page 4 of 8 MEDICATION RECONCILIATION LIST (For REFERENCE only) Medication allergies: Home Medication Reported on Arrival Dosage Route Frequency Last Taken Patient Label Permanent Part of Medical Record

5 Page 5 of 8 1. List any significant hospitalization/surgeries: 2. List any significant medical conditions you have or have had in the past: 3. Circle any of the following conditions you have now or have had in the past: High blood pressure Heart attack Heart arrhythmia Heart palpitations Asthma Fibromyalgia Syndrome COPD Broken nose Deviated nasal septum Heartburn Stomach acid reflux Rheumatism/Arthritis (any type) NONE OF THE CONDITIONS LISTED ABOVE

6 Page 6 of 8 List the following for your typical night s sleep: Work/School Night Weekend/Vacation Nights Time in bed Time you try to fall asleep Time you initially do fall asleep Time you wake up for last time Time you get out of bed for the last time to start the day If you have an unusual sleep schedule, please explain (for example rotating night shifts, permanent graveyard shifts, etc.) If you have trouble sleeping, list how often you wake up, why you wake up (for example: noisy room, noisy pets, no reason, etc.), and what you do to try to fall back asleep.

7 Page 7 of 8 Circle Yes or No for each of the following sleep problems: - Do you snore? Yes No - Do you gasp in your sleep? Yes No - Do you have night sweats? Yes No - Do you have headaches related to sleep? Yes No - Do you have a pain problem that affects your sleep? Yes No - Do you have unpleasant sensations in your legs (or arms) that affect your sleep? Yes No - Do you have leg jerks or kicks that disturb your sleep or others? Yes No - Do you ever suddenly develop muscle weakness or lose muscle tone or control while fully awake? Yes No - When falling asleep or waking up, do you ever feel paralyzed or unable to move? Yes No - When falling asleep or waking up, do you ever see things or hear things that you know are not there? Yes No - Do you talk in your sleep? Yes No - Do you walk in your sleep? Yes No - Do you have violent episodes of sleep-walking? Yes No - Do you frequently wake up startled and feeling panicky? Yes No - Do you have frequent nightmares? Yes No

8 Page 8 of 8 How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done any of these things recently, try to work out how they would affect you. USE THE FOLLOWING SCALE TO CHOOSE THE MOST APPROPRIATE NUMBER FOR EACH SITUATION. PLEASE ANSWER ALL OF THE QUESTIONS. Sitting and reading Watching T.V. 0 Would never doze 1 Slight chance of dozing 2 Moderate chance of dozing 3 High chance of dozing Sitting, inactive in a public place (i.e., meeting or theater) As a passenger in a car for an hour Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few seconds in traffic

Why are you being seen at Frontier Diagnostic Sleep Center?

Why are you being seen at Frontier Diagnostic Sleep Center? 8425 South 84th Street Suite B Omaha, NE 68127 Phone: 402.339.7378 Fax: 402.339.9455 SLEEP QUESTIONNAIRE NAME: ADDRESS: Last First MI Street Address DATE City State Zip PHONE: ( ) BIRTHDATE: HEIGHT: WEIGHT:

More information

INSOMNIA CLINIC SLEEP HISTORY QUESTIONNAIRE PART I: IDENTIFYING INFORMATION Name: Date: Street Address: City/State

INSOMNIA CLINIC SLEEP HISTORY QUESTIONNAIRE PART I: IDENTIFYING INFORMATION Name: Date: Street Address: City/State Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste. 120 Denver, CO 80206 Highlands Ranch, CO 80130 DTC Location 7877 South Chester St. Englewood, CO 80112 #1

More information

Full name: Male Female

Full name: Male Female 6700 W. Ninth Ave. Amarillo, TX 79106 Phone (806) 356-5522 www.adcsleepdisorders.com THE EPWORTH SLEEPINESS SCALE Full name: Male Female Date: Age: How likely are you to doze off or fall asleep in the

More information

SLEEP DISORDER ADULT QUESTIONNAIRE

SLEEP DISORDER ADULT QUESTIONNAIRE SLEEP DISORDER ADULT QUESTIONNAIRE Name: Date: Date of Birth (month/day/year): / / Gender: ο Male ο Female Marital Status: ο Never Married ο Married ο Divorced ο Widowed Home Address: City: Zip: Daytime

More information

Please describe any past professional evaluations or treatments for your sleep problems, including what was and was not helpful?

Please describe any past professional evaluations or treatments for your sleep problems, including what was and was not helpful? Name: Age: Gender: Male Female Date of Birth (month/day/year): / / Race: Marital Status: Never married Married Divorced Widowed Home Address: City: ZIP: Daytime Phone: ( ) Evening Phone: ( ) _ Cell Phone:

More information

Sleep Disorders Center 505-820-5363 455 St. Michael s Dr. 505-989-6409 fax Santa Fe, New Mexico 87505 QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN:

Sleep Disorders Center 505-820-5363 455 St. Michael s Dr. 505-989-6409 fax Santa Fe, New Mexico 87505 QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN: Sleep Disorders Center 505-820-5363 455 St. Michael s Dr. 505-989-6409 fax Santa Fe, New Mexico 87505 QUESTIONNAIRE NAME: DOB: REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: Do you now have or have you had:

More information

Sleep History Questionnaire

Sleep History Questionnaire Sleep History Questionnaire Name Address Daytime Phone Height Evening Phone Weight Weight 5yrs ago Describe your sleep problem: 1. What time do you go to bed? 2. What time do you wake up? 3. What time

More information

Shipman ENT. Associates Board certified experience. Leading edge solutions. Sleep Questionnaire for Adults

Shipman ENT. Associates Board certified experience. Leading edge solutions. Sleep Questionnaire for Adults Shipman ENT & Associates Board certified experience. Leading edge solutions. 3201 University Dr. E Ste 375 Bryan, TX 77802 Office: 979.731.8284 Fax: 979.774.0875 www.shipmanent.com Sleep Questionnaire

More information

Memorial Hospital Sleep Center. Rock Springs, Wyoming 82901. Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am)

Memorial Hospital Sleep Center. Rock Springs, Wyoming 82901. Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am) Memorial Hospital Sleep Center Rock Springs, Wyoming 82901 Sleep lab Phone: 307-352- 8229 (Mon - Wed 5:00 pm 7:00 am) Office Phone: 307-352- 8390 (Mon Fri 8:00 am 4:00 pm ) Patient Name: Sex Age Date Occupation:

More information

SLEEP QUESTIONNAIRE. Name: Today s Date: Age (years): Your Sex (M or F): Height: Weight: Collar/Neck Size (inches) Medications you are taking:

SLEEP QUESTIONNAIRE. Name: Today s Date: Age (years): Your Sex (M or F): Height: Weight: Collar/Neck Size (inches) Medications you are taking: SLEEP QUESTIONNAIRE Name: Today s Date: Age (years): Your Sex (M or F): Height: Weight: Collar/Neck Size (inches) Medications you are taking: Medical conditions: High blood pressure Heart Disease Diabetes

More information

TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON Center for Sleep Disorders 207 NORTH BONNIE BRAE Denton, Texas (940)

TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON Center for Sleep Disorders 207 NORTH BONNIE BRAE Denton, Texas (940) TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON Center for Sleep Disorders 207 NORTH BONNIE BRAE Denton, Texas 76201 (940)898-7010 Instructions For Sleep Study Name: Appt Date: Time: 1. REGISTER: On the night

More information

Patient Sleep Questionnaire

Patient Sleep Questionnaire Patient Sleep Questionnaire Patient Name: _ Sex: Age: Date: Occupation: _ Usual Work Hours/Days: _ Referring Physician: Family Physician (PCP): Patient s email address: Please complete the following questionnaire

More information

building. 2. Enter Turn the on 5305 and begin Building testing and take the elevator/stairs to the third floor, turn right and go into

building. 2. Enter Turn the on 5305 and begin Building testing and take the elevator/stairs to the third floor, turn right and go into SLEEP DISORDERS CENTER St. Joseph Mercy Ann Arbor 5305 Elliott Drive, Ypsilanti, MI 48197 734-712-2276 / Fax 734-712-2967 Sleep Study Information Home Sleep Apnea Testing Dear,, Your are Sleep scheduled

More information

THE CENTER FOR SLEEP DISORDERS GW- MEDICAL FACULTY ASSOCIATES SLEEP DISORDERS INVENTORY

THE CENTER FOR SLEEP DISORDERS GW- MEDICAL FACULTY ASSOCIATES SLEEP DISORDERS INVENTORY THE CENTER FOR SLEEP DISORDERS GW- MEDICAL FACULTY ASSOCIATES SLEEP DISORDERS INVENTORY Vivek Jain, M.D. Director, The Center for Sleep Disorders GW-Medical Faculty Associates Samuel J. Potolicchio, M.

More information

SLEEP QUESTIONNAIRE THE EPWORTH SLEEPINESS SCALE

SLEEP QUESTIONNAIRE THE EPWORTH SLEEPINESS SCALE SLEEP QUESTIONNAIRE Patient Name: Height: Weight: Date : My Main Sleep Complaint(s) : Trouble sleeping at night.. yes no Falling asleep.. yes no Staying asleep.. yes no Snoring. yes no Stop breathing yes

More information

Emory Program in Sleep Medicine Sleep and Health Questionnaire

Emory Program in Sleep Medicine Sleep and Health Questionnaire Emory Program in Sleep Medicine Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City / State / Zip: Preferred Contact Number: Occupation:

More information

Please have your bed partner assist you with the enclosed questionnaire and bring it, completed, with you to your scheduled sleep appointment.

Please have your bed partner assist you with the enclosed questionnaire and bring it, completed, with you to your scheduled sleep appointment. Welcome! Please read the following document carefully as it contains pertinent information regarding your sleep study, interpretation of your study, and billing information. On behalf of our staff here

More information

Marshall Sleep Disorders Center PATIENT INFORMATION FORM (PLEASE PRINT) DATE: Date of Birth: Age: Sex: M F. Home Phone: ( ) Work Phone: ( )

Marshall Sleep Disorders Center PATIENT INFORMATION FORM (PLEASE PRINT) DATE: Date of Birth: Age: Sex: M F. Home Phone: ( ) Work Phone: ( ) Marshall Sleep Disorders Center PATIENT INFORMATION FORM (PLEASE PRINT) DATE: Name: Last First MI SSN# Address: Street City State zipcode Date of Birth: Age: Sex: M F Height: Weight: Home Phone: ( ) Work

More information

Name,, Last First MI DOB Age Current Occupation. Home Phone Work phone Cell Phone

Name,, Last First MI DOB Age Current Occupation. Home Phone Work phone Cell Phone Date / / Name,, Last First MI DOB Age Current Occupation Home Phone Work phone Cell Phone Ethnicity : White Hispanic Asian African American American Indian Pacific Islander Other What is your primary language?

More information

Department of Psychiatry

Department of Psychiatry Sleep Clinic Patient Information Questionnaire Name: Date: Telephone Numbers: Home:( ) Work:( )_Cell:( ) Referring Physician: Primary Care Physician: _ ( )Daytime Sleepiness ( )Difficulty falling asleep

More information

Is Obstructive Sleep Apnea Affecting Your Daily Life?

Is Obstructive Sleep Apnea Affecting Your Daily Life? Is Obstructive Sleep Apnea Affecting Your Daily Life? Is Obstructive Sleep Apnea Affecting Your Daily Life? Do you feel sleepy during the day no matter how much sleep you get? Can you fall asleep easily

More information

Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes ( ) No ( ) if yes, explain:

Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes ( ) No ( ) if yes, explain: Accredited by the American Academy of Sleep Medicine Sleep History Questionnaire Name: Ht: Wt: Neck Size: Allergies to Medications: Yes ( ) No ( ) if yes, explain: Allergies to environmental agents: Yes

More information

Assessment of Fitness to Drive to be completed by medical practitioner

Assessment of Fitness to Drive to be completed by medical practitioner COMMERCIAL VEHICLE DRIVER MEDICAL ASSESSMENT This Medical Assessment meets the requirements of the following Western Australian Government Authorities; Department of Consumer and Employment Protection,

More information

Pacific Sleep Program

Pacific Sleep Program Name: Date of Birth: / / Pacific Sleep Program Portland & Astoria Setting the standard in sleep medicine for over 30 years PATIENT QUESTIONNAIRE Hello, You have been referred to the Pacific Sleep Program

More information

Sleep Disorders Interview

Sleep Disorders Interview Sleep Disorders Interview Name: Gender: M F Marital Status: M Sep Single D W Day Phone: Date of Birth: / / Education (Yrs): Yr Mth Day Referral Source: Interviewer: Nature of Sleep-Wake Problem In a typical

More information

SLEEP SCREENING QUESTIONNAIRE

SLEEP SCREENING QUESTIONNAIRE SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your

More information

Part 1 ASSESSING FITNESS TO DRIVE. Driver Health Questionnaire

Part 1 ASSESSING FITNESS TO DRIVE. Driver Health Questionnaire Part 1 ASSESSING FITNESS TO DRIVE Driver Health Questionnaire The Driver Health Questionnaire is a screening tool to help identify conditions that might affect a person s capacity to drive safely. It is

More information

GEORGIA UROLOGY AMBULATORY SURGERY CENTER 2685 MILSCOTT DRIVE, DECATUR, GA 30033 TELEPHONE 404-292-7333

GEORGIA UROLOGY AMBULATORY SURGERY CENTER 2685 MILSCOTT DRIVE, DECATUR, GA 30033 TELEPHONE 404-292-7333 GEORGIA UROLOGY AMBULATORY SURGERY CENTER 2685 MILSCOTT DRIVE, DECATUR, GA 30033 TELEPHONE 404-292-7333 PLEASE PRINT, COMPLETE AND RETURN THE FOUR PAGE PRE-OPERATIVE HEALTH QUESTIONNAIRE WITHIN 5 DAYS

More information

LifeCoach: Overcoming Depression. Session 1 Understanding Insomnia

LifeCoach: Overcoming Depression. Session 1 Understanding Insomnia LifeCoach: Overcoming Depression Session 1 Understanding Insomnia Lesson 1: Introduction to Conquering Insomnia Conquering Insomnia What Is Insomnia? Let s start by defining insomnia. Insomnia means not

More information

Sleep Disorders , The Patient Education Institute, Inc. [www.x-plain.com] nr Last reviewed: 03/06/2011 1

Sleep Disorders , The Patient Education Institute, Inc. [www.x-plain.com] nr Last reviewed: 03/06/2011 1 Sleep Disorders Introduction Sleep disorders are very common conditions that can be overcome. It is important to understand what affects sleep and the importance of sleep. This reference summary will help

More information

SLEEP QUESTIONNAIRE AND WAKEFULNESS

SLEEP QUESTIONNAIRE AND WAKEFULNESS SLEEP QUESTIONNAIRE AND WAKEFULNESS (SQAW) PATIENT: DOCTOR: DATE COMPLETED: Must Be Completed by Appointment Date 7423-029-W-BKLT 11-1-09 For questions to be answered on a scale of 1 to 5, please circle

More information

SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE. Please bring this completed questionnaire with you to your sleep clinic appointment.

SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE. Please bring this completed questionnaire with you to your sleep clinic appointment. SLEEP DISORDERS CENTER Please bring this completed questionnaire with you to your sleep clinic appointment. Patient s Name: Date: Referring Physician: Clinic Location: 1. Why are you being seen in the

More information

elf-awareness Toolkit

elf-awareness Toolkit S Snoring & Sleep Apnea elf-awareness Toolkit Snoring: Your Dentist Can Test So You Can Rest 2009 Snoring Isn t Sexy, LLC S Snoring & Sleep Apnea elf-awareness Toolkit Snoring: Your Dentist Can Test So

More information

Preparation guidelines for your Child s Sleep Study

Preparation guidelines for your Child s Sleep Study Preparation guidelines for your Child s Sleep Study Patient Sticker here Maintain your child s regular night sleeping and nap schedule for several days before the study. On the day of the study, do not

More information

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE

HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE HEALTH RISK ASSESSMENT (HRS) QUESTIONNAIRE The Health Risk Assessment (HRA) questionnaire provides participants with an evaluation of their current health and quality of life. The assessment promotes health

More information

Insomnia affects 1 in 3 adults every year in the U.S. and Canada.

Insomnia affects 1 in 3 adults every year in the U.S. and Canada. Insomnia What is insomnia? Having insomnia means you often have trouble falling or staying asleep or going back to sleep if you awaken. Insomnia can be either a short-term or a long-term problem. Insomnia

More information

EEG (brain wave patterns) Eye movement Muscle tension Breathing effort and airflow Heart rate Body movement Oxygen content in the blood

EEG (brain wave patterns) Eye movement Muscle tension Breathing effort and airflow Heart rate Body movement Oxygen content in the blood Sleep Disorders Sleep Disorders According to the National Institutes of Health, at least 70 million Americans of all ages suffer from a sleep problem, with nearly 60 percent having a chronic disorder.

More information

NEW PATIENT HISTORY Mark L. Prasarn, M.D.

NEW PATIENT HISTORY Mark L. Prasarn, M.D. NEW PATIENT HISTORY Mark L. Prasarn, M.D. Date: Name: Age: Height: Weight: Pharmacy: Phar. Phone#: Primary Care M.D. Referring M.D.: What is your Chief Complaint? What makes the pain better? Neck Pain

More information

Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495

Pain Questionnaire. Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Center for Interventional Pain 1000 Health Center Drive, Suite 106 Mattoon, IL 61938 217-238-4495 Pain Questionnaire Date First name Last name Middle initial Date of birth Sex Male Female Height Weight

More information

Don t just dream of higher-quality sleep. How health care should be

Don t just dream of higher-quality sleep. How health care should be Don t just dream of higher-quality sleep. How health care should be Many of our patients with sleep disorders don t realize there s another way of life, a better way, until they are treated. Robert Israel,

More information

Understanding. Sleep Disorders. Bob, diagnosed in 2005.

Understanding. Sleep Disorders. Bob, diagnosed in 2005. Understanding Sleep Disorders Bob, diagnosed in 2005. What Are Sleep Disorders? Many sleep disorders are brain disorders that cause interruptions in sleep patterns. They prevent people from getting enough

More information

new patient questionnaire

new patient questionnaire new patient questionnaire Name: Middle: Last: Health Card#: Date of Birth: Home Address: City / Prov: Home Phone: Family Doctor: Work / Cell: Postal Code: Referring Doctor: E-mail: State the reason for

More information

CONCORD INTERNAL MEDICINE TESTOSTERONE DEFICIENCY PROTOCOL

CONCORD INTERNAL MEDICINE TESTOSTERONE DEFICIENCY PROTOCOL CONCORD INTERNAL MEDICINE TESTOSTERONE DEFICIENCY PROTOCOL Douglas G. Kelling, Jr., MD Carmella Gismondi-Eagan, MD, FACP George C. Monroe, III, MD Revised April 29, 2012 The information contained in this

More information

Stroke and Sleep Disorders

Stroke and Sleep Disorders Stroke and Sleep Disorders What is a sleep disorder? Getting a good night s sleep is an important part of stroke recovery, yet sleep problems are common among stroke survivors. When sleep problems go on

More information

Do you have a sleep disorder?

Do you have a sleep disorder? Do you have a sleep disorder? Take this self-test Yes No Have you been told that you snore? Do you often feel tired or have a headache when you awake in the morning? Do you awaken frequently during the

More information

MedStar Georgetown University Hospital Sleep Disorders Center Pediatric Patient Information Packet

MedStar Georgetown University Hospital Sleep Disorders Center Pediatric Patient Information Packet 3800 Reservoir Road, NW Washington DC, 20007 5 th Floor Main Building #5411 MedStar Georgetown University Hospital Sleep Disorders Center Pediatric Patient Information Packet Appointment Time: 8:30pm Please

More information

This education material was made possible by a Grant from the California Department of Justice,

This education material was made possible by a Grant from the California Department of Justice, Managing Insomnia The following information is based on the general experiences of many prostate cancer patients. Your experience may be different. If you have any questions about what prostate cancer

More information

Patient Packet. Sleep/Wake Disorders Center Centers of Excellence

Patient Packet. Sleep/Wake Disorders Center Centers of Excellence Patient Packet Sleep/Wake Disorders Center Centers of Excellence Sleep Center directions To help determine your medical treatment, your physician has requested that you undergo sleep testing at the Community

More information

Diabetes and Sleep Problems. Sleep Study

Diabetes and Sleep Problems. Sleep Study Diabetes and Sleep Problems Sleep Study Diabetes and Sleep Problems Sanjay R. Patel, MD, MS Suzanne M. Bertisch MD, MPH Amy P. Campbell, MS, RD, CDE David Erani, MD This booklet was developed by Joslin

More information

SUMMA HEALTH SYSTEM. Sleep Medicine Services

SUMMA HEALTH SYSTEM. Sleep Medicine Services SUMMA HEALTH SYSTEM Sleep Medicine Services Contents Why should I be concerned about a sleep disorder? 2 Evaluate Your Daytime Sleepiness 3 Common sleep disorders 5 About sleep studies 6 What to expect

More information

What you Need to Know about Sleep Apnea and Surgery

What you Need to Know about Sleep Apnea and Surgery What you Need to Know about Sleep Apnea and Surgery UHN For patients with sleep apnea who are going to have surgery Read this brochure to learn: What sleep apnea is Risks of having sleep apnea when going

More information

REFERRAL & RECORDS POLICY

REFERRAL & RECORDS POLICY School of Medicine Department of Neurology HSC, Level 12, Room 020 Stony Brook, NY 11794-8121 Tel: (631) 444-2599 Fax: (631) 444-1474 REFERRAL & RECORDS POLICY Effective immediately it will be the policy

More information

Sleep Difficulties. Insomnia. By Thomas Freedom, MD and Johan Samanta, MD

Sleep Difficulties. Insomnia. By Thomas Freedom, MD and Johan Samanta, MD Sleep Difficulties By Thomas Freedom, MD and Johan Samanta, MD For most people, night is a time of rest and renewal; however, for many people with Parkinson s disease nighttime is a struggle to get the

More information

MEDICATION GUIDE Xyrem (ZĪE-rem) (sodium oxybate) oral solution CIII

MEDICATION GUIDE Xyrem (ZĪE-rem) (sodium oxybate) oral solution CIII MEDICATION GUIDE Xyrem (ZĪE-rem) (sodium oxybate) oral solution CIII Read this Medication Guide carefully before you start taking Xyrem and each time you get a refill. There may be new information. This

More information

STRESS INDICATORS QUESTIONNAIRE

STRESS INDICATORS QUESTIONNAIRE The Counseling Team International 1881 Business Center Drive, Suite 11 San Bernardino, CA 92408 (909) 884-0133 www.thecounselingteam.com STRESS INDICATORS QUESTIONNAIRE This questionnaire will show how

More information

Migraine Treatment. Step 1: Fill out the Migraine Log for 4 weeks

Migraine Treatment. Step 1: Fill out the Migraine Log for 4 weeks Dr. Walter L. Bernacki Dr. Christopher G. Zochowski 300 Polaris Parkway Suite 2650 Westerville, OH 43082 Migraine Treatment Please read this information before you begin to fill out the paperwork. Each

More information

SLEEP AND PARKINSON S DISEASE

SLEEP AND PARKINSON S DISEASE A Practical Guide on SLEEP AND PARKINSON S DISEASE MICHAELJFOX.ORG Introduction Many people with Parkinson s disease (PD) have trouble falling asleep or staying asleep at night. Some sleep problems are

More information

INITIAL PATIENT ASSESSMENT AND HISTORY

INITIAL PATIENT ASSESSMENT AND HISTORY DATE INITIAL PATIENT ASSESSMENT AND HISTORY Thank you for choosing us to assist in your medical care. Please fill out this form completely to assist us with your visit. First Name MI Last Name Age: Marital

More information

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions

VEIN CLINIC OF NORTH CAROLINA 3318 HEALY DR. WINSTON SALEM, NC 27103 PH. 336-768-3530 FAX- 768-1329. Scott W. Baker, MD. Patient Instructions 18 HEALY DR. WINSTON SALEM, NC 710 PH. 6-768-50 FAX- 768-19 Scott W. Baker, MD Patient Instructions 1. Bring a list of all regular medications and dosages.. Bring your insurance card and all necessary

More information

Cervical Spine. New Patient Form

Cervical Spine. New Patient Form Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right

More information

Overcoming Insomnia. A Five Session, Interactive CBT Program for Insomnia. Copyright, 2005-present

Overcoming Insomnia. A Five Session, Interactive CBT Program for Insomnia. Copyright, 2005-present Overcoming Insomnia A Five Session, Interactive CBT Program for Insomnia Copyright, 2005-present Session 1 Understanding Insomnia Lesson 1: Introduction to the Overcoming Insomnia Program What Is Insomnia?

More information

Sleep & Multiple Sclerosis

Sleep & Multiple Sclerosis Sleep & Multiple Sclerosis Produced by Lind Publishing, Inc. Living with MS MSology Essentials Series Sleep & Multiple Sclerosis Developed by MSology with the invaluable assistance of multiple sclerosis

More information

Quick Read Series. Information for people with seizure disorders

Quick Read Series. Information for people with seizure disorders Quick Read Series Information for people with seizure disorders 2003 Epilepsy Foundation of America, Inc. This pamphlet is designed to provide general information about epilepsy to the public. It does

More information

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:

More information

Motor Vehicle Accident - New Patient

Motor Vehicle Accident - New Patient Motor Vehicle Accident - New Patient Today's Date: Patient Name: Auto Insurance Company of Car You Were In: Phone: Insurance Agent: Phone Was A Police Report Made? Have You Informed Your Agent of Your

More information

Patient Questionnaire for Men

Patient Questionnaire for Men Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial

More information

Healthbridge Chiropractic and Rehabilitation 137 E. Broadway Bel Air, MD Dr. Jason Menges, D.C. Lic#S Address: Apt# City State Zip

Healthbridge Chiropractic and Rehabilitation 137 E. Broadway Bel Air, MD Dr. Jason Menges, D.C. Lic#S Address: Apt# City State Zip Today s /State? PERSONAL Name: First MI Last Nickname Address: Apt# City State Zip Social Security#: / / Male/Female Single/Married/Divorced/Widowed/Separated Race: White/Black/African American/Other:

More information

Sleep and sleep problems

Sleep and sleep problems STUDENT HEALTH CENTRE Sleep and sleep problems Sleep and sleep problems: contents Sleepless nights 1 The different stages of sleep 1 Sleep problems 3 Causes of sleep problems 3 Sleep FAQ 4 Sleep advice

More information

What is the most important information I should know about TREXIMET?

What is the most important information I should know about TREXIMET? PATIENT IMPORTANT SAFETY INFORMATION What is the most important information I should know about TREXIMET? TREXIMET may increase your chance of a heart attack or stroke that can lead to death. TREXIMET

More information

Old Republic Insurance Company of Canada *January Sleep Apnea

Old Republic Insurance Company of Canada *January Sleep Apnea Old Republic Insurance Company of Canada *January 2014 Sleep Apnea Obstructive sleep apnea (OSA) is a condition that causes a blockage of air while a person sleeps. This blockage is caused by soft tissues

More information

Please take the time to answer all questions that apply to your problem as completely as possible. Thank You.

Please take the time to answer all questions that apply to your problem as completely as possible. Thank You. USC Center for Spinal Surgery Online Consultation Form Please take the time to answer all questions that apply to your problem as completely as possible. Thank You. Date Referring Doctor/Primary Doctor

More information

Underwriting Sleep Apnea

Underwriting Sleep Apnea Underwriting Sleep Apnea Joel Weiner, MD, FLMI April 29, 2014 WAHLU The Northwestern Mutual Life Insurance Company Milwaukee, WI A Brief Survey Before We Get Started The Weiner Sleepiness Scale How likely

More information

Patient Self-Evaluation for ATTENTION DEFICIT/HYPERACTIVITY DISORDER

Patient Self-Evaluation for ATTENTION DEFICIT/HYPERACTIVITY DISORDER Patient Self-Evaluation for ATTENTION DEFICIT/HYPERACTIVITY DISORDER Student Name Student No. Date STUDENT'S PRIMARY CONCERN (Please state your primary concern) WHAT LED YOU TO SEEK AN EVALUATION NOW?

More information

USF DEPARTMENT OF CARDIOLOGY NEW PATIENT INTAKE FORM

USF DEPARTMENT OF CARDIOLOGY NEW PATIENT INTAKE FORM Personal Data Name: Date: Date of Birth: Age: Occupation: Marital Status: Single Married Divorced Widowed Birth Place: Education Level: Reason for Cardiac Referral: Physician referring for Cardiac assessment:

More information

Medical Massage Client Intake Form Medical Massage Client Intake Form

Medical Massage Client Intake Form Medical Massage Client Intake Form Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.

More information

Snoring. As you breathe, air passes in and out of your lungs through your mouth, nose, and throat.

Snoring. As you breathe, air passes in and out of your lungs through your mouth, nose, and throat. Snoring Introduction Snoring is the harsh sound that is made when the flow of air through your mouth and nose is blocked while you are sleeping. Snoring can be an annoyance for your partner or other people

More information

How To Avoid Drowsy Driving

How To Avoid Drowsy Driving How To Avoid Drowsy Driving AAA Foundation for Traffic Safety Sleepiness and Driving Don t Mix Feeling sleepy is especially dangerous when you are driving. Sleepiness slows your reaction time, decreases

More information

Questions Concerning Activities of Daily Living (ADL)

Questions Concerning Activities of Daily Living (ADL) Questions Concerning Activities of Daily Living (ADL) Please fill out this form carefully and mark only one box for each question. 1. How well can you perform personal self care activities including washing,

More information

Anxiety, Panic and COPD

Anxiety, Panic and COPD Anxiety, Panic and COPD What is anxiety? Anxiety is a feeling of worry or unease about something you are not sure about or cannot control. Anxiety can be mild to severe. It can be brief, such as only a

More information

Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS

Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS Cardiff and Vale Spinal Unit Mr M J H McCarthy FRCS NECK / ARM PAIN QUESTIONNAIRE Affix Patient Label This document contains a series of standard assessments that are very useful in helping us assess your

More information

SPINE PATIENT HISTORY FORM

SPINE PATIENT HISTORY FORM Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print

More information

Questionnaire Version A

Questionnaire Version A Appendix 2: Questionnaire Used in the Pilot Test in Five Selected Countries ESCAP/WHO Project on Health and Disability Statistics Disability Question Set Testing Study One: Specificity and Sensitivity

More information

Obstructive Sleep Apnoea

Obstructive Sleep Apnoea Obstructive Sleep Apnoea What is obstructive sleep apnoea? People who suffer from Obstructive Sleep Apnoea (OSA) reduce or stop their breathing for short periods while sleeping. This can happen many times

More information

SLEEP STUDY PATIENT CHECKLIST

SLEEP STUDY PATIENT CHECKLIST SLEEP STUDY PATIENT CHECKLIST Bring all of the following with you on the night of your study: Your health insurance card Your driver s license This packet of completed forms A form of payment (if applicable)

More information

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING

More information

BBC LEARNING ENGLISH 6 Minute English Is modern life making us tired?

BBC LEARNING ENGLISH 6 Minute English Is modern life making us tired? BBC LEARNING ENGLISH 6 Minute English Is modern life making us tired? NB: This is not a word-for-word transcript Hello and welcome to 6 Minute English. I'm and I'm. So, did you sleep well last night? Um,

More information

Insured Party Information (please complete if the insurance is not in your name)

Insured Party Information (please complete if the insurance is not in your name) Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr

More information

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850

CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850 CAYUGA CENTER FOR HEALTHY LIVING Geoffrey E. Moore, MD FASCSM Shannan Simkin, NP Lisa Proctor, NP ISLAND HEALTH & FITNESS COMPLEX ITHACA, NY 14850 TELEPHONE: (607) 252-3590 FAX: 607-252-3592 An appointment

More information

Building a. With Your Doctor

Building a. With Your Doctor Building a With Your Doctor As a mental health consumer, there are many things you can do to improve your care and get more out of life. Learning more about your illness, current treatment options and

More information

Emory Eye Center New Patient Questionnaire

Emory Eye Center New Patient Questionnaire Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions

More information

Sleep and Medical History Questionnaire

Sleep and Medical History Questionnaire Sleep and Medical History Questionnaire NAME: AGE: PRIMARY MD: REFERRING MD: 1. It is important for you to be as accurate as possible in answering the following questions. The purpose of this questionnaire

More information

TAKING CARE OF YOUR ASTHMA

TAKING CARE OF YOUR ASTHMA TAKING CARE OF YOUR ASTHMA WHAT IS ASTHMA? Asthma is a disease that affects the lungs. If you have asthma, you have it all the time, but will have an asthma attack only when something, known as a trigger,

More information

Patient Information. WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number the complaints with #1 being the most important.

Patient Information. WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number the complaints with #1 being the most important. SLEEP SCREEIG QUESTIOAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your

More information

PREPARATION FOR ESOPHAGEAL MOTILITY STUDY

PREPARATION FOR ESOPHAGEAL MOTILITY STUDY Patient Name: Date of Study: Time to Arrive: Location: Phone: PREPARATION FOR ESOPHAGEAL MOTILITY STUDY 1. Have nothing to eat or drink for at least 6 hours before the exam. After the exam you may eat

More information

Myofascial Trigger Point Therapy Patient Medical History Form

Myofascial Trigger Point Therapy Patient Medical History Form Myofascial Trigger Point Therapy Patient Medical History Form Please complete this form before your Initial Myofascial Trigger Point Therapy Evaluation and bring it with you to your appointment. Thank

More information

Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist

Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist 1 Helen G. Jenne, Psy.D.,FAACP Board Certified Clinical Psychologist Adult Questionnaire Patient Name: Date: Street Address: City, State: Zip Code: Home Phone: Work Phone: Cell Phone: Best Number to reach

More information

Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip

Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip Texas Sinus Center PATIENT REGISTRATION 1. PATIENT INFORMATION Name Birth date Soc Sec# Address City/State Zip Home Phone Work Phone Cell Phone Marital Status S / M / W / D Student FT / PT Male / Female

More information

INSOMNIA SELF-CARE GUIDE

INSOMNIA SELF-CARE GUIDE INSOMNIA SELF-CARE GUIDE University of California, Berkeley 2222 Bancroft Way Berkeley, CA 94720 Appointments 510/642-2000 Online Appointment www.uhs.berkeley.edu All of us have trouble sleeping from time

More information

Falling Asleep & Staying Asleep Handout

Falling Asleep & Staying Asleep Handout Falling Asleep & Staying Asleep Handout This handout contains information that may help if you have difficulty falling asleep or staying asleep. In the pages that follow, you will learn about sleep disorders

More information

Many women have problems with hyperventilation during pregnancy, but it usually goes away on its own after delivery.

Many women have problems with hyperventilation during pregnancy, but it usually goes away on its own after delivery. Hyperventilation Table of Contents Topic Overview Check Your Symptoms Home Treatment Prevention Preparing For Your Appointment Related Information Credits Topic Overview Hyperventilation is breathing that

More information