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

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1 TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON Center for Sleep Disorders 207 NORTH BONNIE BRAE Denton, Texas (940) Instructions For Sleep Study Name: Appt Date: Time: 1. REGISTER: On the night of the study, come to the Lobby of Texas Health Presbyterian Hospital Denton-The Center For Women side of the hospital. This is the entrance that faces Bonnie Brae. At this time, you will register and pay any copay or deductible amounts due. 2. MEDICATIONS: Take your medications as your doctor has prescribed, Preferably before you arrive at the Sleep Lab. Bring any medications you must take while in the Sleep Lab in the original container from your pharmacy. Bring in a list of your current medications that you are taking. 3. CLEAN DRY HAIR: Please arrive with clean, dry hair with no hair products such as spray, oil, mousse or conditioner. 4. SLEEPING CLOTHES: Bring in something comfortable to sleep in, preferably a two piece such as pajamas or shorts and a t-shirt. 5. PERSONAL ITEMS: Toothbrush and toothpaste, hairbrush or comb, shampoo and blow dryer if desired. Paste will be used to apply electrodes in your hair-this will easily wash out. 6. BRING PILLOW: We can supply a pillow, however your own may be more comfortable. 7. NO CAFFEINE PRODUCTS: Bring something to read or snack if desired. A television is available in each sleep room. 8. SPECIAL NEEDS: If you have special needs or currently use home oxygen, please inform us as soon as possible. 9. QUESTIONS: If you have any questions please feel free to contact us with any questions you may have at (940) CANCEL STUDY: If you need to cancel or reschedule please call us at the number above at least 48 hours before your appointment. 11. PAPERWORK: Please bring all paper work with you.

2 CENTER FOR SLEEP DISORDERS SLEEP HISTORY Name: DOB:AGE: DATE: If you were referred to our office by a physician, please list the name:dr. If not, how did you learn about our office?_ What is your main sleep problem?_ How long have you had this problem? Please list any previously diagnosed sleep disorders. Check any of the following that apply: Loud snoring Awaken gasping for breath Do not feel restored when I awaken Become sleepy during the day Awaken too early Difficulty falling asleep Difficulty remaining asleep Breathing/Snoring pauses for brief periods of sleep (please check any/all that apply) sitting talking riding eating driving standing have you ever had an automobile accident as a driver Sleep Environment My bedroom is (loud/quiet and (light/dark) My mattress is (soft/hard/just right) Do you fall asleep with television on? Yes No Is your sleep disturbed because of your partner or others in your household? (children/pets) Yes No Occupation: What do you do at work? How does your sleep problem affect your work? Weight: Now 1 yr ago 5yrs ago Collar: Now 1 yr ago 5yrs ago Epworth Sleepiness Scale How likely are you to doze off/fall asleep in the following situations in contrast to feeling just tired? This refers to your usual way of life in recent time. Even if you have not 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: Sitting and reading... Watching Television... Sitting in active, in a public place ex., a theater or a meeting... As a passenger in a car for an hour without a break... Lying down to rest in the afternoon when circumstances permit... Sitting and talking with someone... Sitting quietly after a lunch without alcohol... In a car, while stopped for a few minutes in traffic... Total...

3 CENTER FOR SLEEP DISORDERS MEDICAL HSITORY-Please check any of the following Name: ( ) High blood pressure ( ) Diabetes ( ) Anemia ( ) skin condition ( ) Asthma/Emphysema ( ) Acid Reflux ( ) Anxiety ( ) Fibromyalgia ( ) Thyroid condition ( ) Seizures ( ) Vision problems ( ) Depression ( )Stroke ( ) Head injury or brain surgery ( ) Other psychiatric disorder: ( ) Other medical problems {please list}: ( ) Prior Surgeries {please list}: ( ) Heart disease : Congestive Heart Failure ( CHF ), Heart failure, Myocardial infarction ( MI ), Heart attack, Pacemaker, other: Medication's: Do you take anything to help you sleep? Yes No If yes, what? _ How often? List any current medications and dosages, including both prescriptions/over the counter medications: If you are on oxygen, how much? liter/min. How many hours/day?_ Drug Allergies (Please list): Social History: Do you smoke? Did you previously smoke? Do you dip or chew? How many years of smoking? How much per day? Do you drink alcohol? How much? drinks per( day/week/month) How much caffeinated coffee, tea or cola do you drink daily? Family History (please check all that apply) Is there any family history of: Sleep Apnea Heavy Snoring Narcolepsy Other Disturbances Restless Legs Syndrome Mother Father Sister(s) Brother(s)

4 Name: Date: Indicate on average how often you experience the following symptoms per week. Times Weekly Symptoms My mind races with many thoughts when I try to fall asleep. I often worry whether or not I will be able to fall asleep. Fatigue Anxiety Memory impairment Inability to concentrate Depression Awaken with a dry mouth Morning headaches Pain which delays or prevents my sleep Pain which awakens me from sleep Vivid or life like visions (people in room, etc ) as you fall asleep or wake up Inability to move as you are trying to go to sleep or wake up Sudden weakness or feel your body go limp when you are angry or excited Irresistible urge to move legs or arms Creeping or crawling sensations in your legs before falling asleep Legs or arms jerking during sleep Sleep talking Sleep walking Nightmares Fall out of bed Heartburn, sour belches, regurgitation, or indigestion which disrupts sleep. Bed wetting Frequent urination disrupting sleep Teeth grinding Wheezing or cough disrupting sleep Sinus trouble, nasal congestion or postnasal drip interfering with sleep Shortness of breath Irritability Please be as accurate as possible. Indicate AM or PM. If you work and/or sleep schedule changes during the week, then indicate your schedule using "shift work" column. Activity lay down in bed? turn lights out? Time you usually fall asleep in (minutes, hours). How many times do you awaken each night? Number of times you have difficulty returning to sleep The total time you spend awake in bed. Final time you wake up from sleep. usually get out of bed from sleep? How many hours of sleep do you get on average? If you take naps, how long? Begin work time End work time Usual Schedule Week- Ends Shift Work Other Comments:

5 Name: Section I Complete This Section Before Bed Section II Complete This Section After Awakening Day/Date Bedtime Mood: 1= Very Good 10=Very Bad Medication s Taken Bedtime Light turned out Approximate Time to fall Asleep Number of Awakenings During night Wake up Time Total Sleep Time Wake up Mood: 1= Very Good 10= Very Bad

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